Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> or <br /> rr 5tate of Callfomfa <br /> CIWMBIBa,tew a gement <br /> Survey Form - Page 1 1 3 1 0 1 3 8 2 <br /> California Integrated Waste 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: I 0 Routine 0 Reinspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. 0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name '7 <br /> Inspected`By Inspector <br /> Physical Address o <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> 0 P QPM <br /> f� tel;n►� <br /> Operational Statusl Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> C <br /> J 0 Active Q Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ®Indoor . . <br /> 0 0 Inactive ®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 ®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 Facilityilililal� ry <br /> =F <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires _ <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. �( <br /> 0 0. PRC§42956-RegistrationlDecal 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 <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 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities Wit : <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q 0 1 Other: § "n — <br /> Comments %J(,(s,- („V ay ' f U[S %AV 'W-1C ol-+X �1 [mgr+-��5 <br /> itD „ <br /> �^S c.�-AJC M•�--/-res j s W Q_P_ a.)a l 1.-b Lam. cue.y <br /> Inspection Form Included:Q <br /> Comments Included:0 <br /> inelI 1ss Rep's Signature Phone Number I s Signature Phone Number <br /> INSTRUCTIONS O BACK „: E.X M P E 2 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0609004.0024 <br />