Laserfiche WebLink
Waste Tire Sueey & Inspection Repor Inspection Report Number <br /> �f« State of California <br /> CJWMB grated 1steManage) Survey Form - Page 1 18 - 1 0 1 4 7 2 4 <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 Q t 1- ( C5 C ®Routine 0 Re-Inspection 0 Referral 0 Observation <br /> Local + ��, If Referral,choose referral type(Fill one) <br /> Identifier: �� -�• 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name - n / Inspected By Inspector <br /> F>lGX Physical Address 1�n w->W- (mss,c�C r t l lam.cr �. r ( /� L)�U�-'•� S <br /> ��{� Inspection Date I I 0 C� <br /> d' � Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> ..�' 0 PM 0 PM <br /> Operational Status! Tire TypeBusiness Role Storage Type <br /> Tire Count(Whole/PTE) © (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f f 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 0 Closed 0Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 1 0 Inactive 0 Truck <br /> Longitude _ Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body •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 FacilityENFt?RGMIaT$7`AiS <br /> ;V. A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Vlolatltan Ext$nsion <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance 00006.0 i <br /> 0 0 PRC§42956-Registration/Decal in Vehicle m m <br /> 01 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date J I I <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 (R9gUl �ffofNftytprXT} <br /> 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years - 1 <br /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q RefeMttic fr ftgif�pi �j1t, <br /> T ? ` <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 ✓ i //r <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators10 0 <br /> Other: § <br /> Comments �O�I C`��f'—�( '� C TIrV�- <br /> w�a[:��i l fL C► T < �`� *5 41k-v— . Artl ��J,-� l vrF= !S !A,,,2— 61 l Gia <br /> 1 n IL / 1 -f-,•� �j <br /> Inspection Form Included: 0 <br /> Comments Included: ® ()09)30- 3,5�3 7� <br /> Business Rep Signature Phone Number I ector`s Signatu a Phone Number <br /> r— 62081 <br /> INSTRUCTIONS ON BACK Carrect:0 Inc�t�rect: vJ a t��P i <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />