Laserfiche WebLink
G! <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> state 181(ornia Survey Form - Page 1 11 - 0 1 0 7 3 3 <br /> CIWMB 181(New nage <br /> CaliTomis Integrated Waste Management Board <br /> Part A•Survey _ _ BLU_ E OR BLACK INK PEN <br /> Business Profile Inspection DataAs <br /> TPID- Inspection O Inspection Type (Fill one) <br /> Site Suffix: L 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local � If Referral,choose referral type(Fill one) <br /> Identifier: ���111���' 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name •fll ' Inspected By Inspector <br /> R POw-f.G( TrKInc <br /> Physical Addres 3 � — •� O � J A.. M w ��]/Yf C1 <br /> 108 co,vk'p bal Ave. 3—�- <br /> `e C,4 9!53-; D Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> 0 PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(WholelPTE) (Fill one only) (Fill all thatapply) (Fill all that apply) (Fill all that apply) <br /> ®Active 0 Passenger 4 Generator ®Outdoor <br /> O' 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair a Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ; <br /> 0 0 PRC§42951 Waste Tire Hauler RegistrationandTransport of Tires <br /> 0 0 :t 4c <br /> PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB T <br /> 0 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years # <br /> 0 0 <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste The Haulers <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities -� w <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators e , <br /> 1010 1 Other: § ` <br /> Comments S C6'fer �/ 1 WQ,S Ko e <br /> l � <br /> IAS° T1^ ✓ice 4- <br /> i riYl�. No <br /> Inspection Form Incuded:0 : 's <br /> Comments ncluded: —7?� <br /> u ess p Signature' Phone Number Ins tos Sign Phone�N9 <br /> INSTRUCTIONS ON BACK <: XM4 A. P El P 13 62061 <br /> ■ li 7 16 5 0}' 0 t_1}6 White Copy:CIWMB Yellow Copy:Operator Pink Copy:LFA, ■ <br />