Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report Number <br /> ■ r9 ■ <br /> r StateMe of CaliforniaCI'rated (Ne wMlSurvey Form - Page 1 1 1 - 1 Q a 6 4 8 3 <br /> California Integrated Matete Management Board <br /> Part A-Survey_ - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> } TPID- _ Inspection Type(Fill one) <br /> Site Suffix:-. Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> identifier: . Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> \� 1 Inspected By Inspector <br /> V <br /> �hj�S t�Sei� S�lvRe / <br /> Physical Ad ss 3 -W <br /> inspection <br /> 1-3Time <br /> Date D 8 / �3 � �S <br /> 'm Time In Time Out <br /> Business Rep Title <br /> Title f to AM Q AM <br /> t>"%, <br /> >" Wo t 0 • 49 � 0 P 0 P <br /> Ow''�G-� <br /> Operational Status Tire Type Business Role Storage Type. <br /> Tire'Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ®Active Q Passenger O Generator Q Outdoor <br /> o Q Closed Q Altered <br /> GPS Latitude Q Hauler ®Indoor <br /> O, Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR Q End-use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer I.Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Dedved Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility `` ' <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> PRC1§42953-Contracts with Registered Waste Tire Haulers. �r <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 14 CCR§18459.1 a b c -Tire Program ID Number from CIWMB A a. <br /> Q Q 14 CCR§18459.2.1,Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years a <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers r <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators u <br /> Q 1 Q 1 Other: § `` " <br /> Comments �c-t,A�1t1 J\",L-:* -�\��P' G-t\Nm_zI ,. O�v�w 0r VST <br /> ,"Al I- s - 06 DO . �a u�� .� - , ,r 1-`�.,J <br /> rP�ava .D� 10 ar vrn.re: �,.-ase �rs . Fa-,t �-► <br /> l <br /> L. les Inspection Form Form Included:Q I KS <br /> Comments <br /> a� <br /> Comments Included:Q, - / 53 76i^a <br /> Business Rep's tgnature Phone Number I e .t Phone Number <br /> INSTRUCTIONS ON BACK �.,; , .. � t'N '1 <br /> X 0 F LE, p 2 62081 <br /> ■ White Copy:ClWMB Yellow Copy:Operator Pink Copy:LEA - - <br /> 052Q204. 11,1 <br />