Laserfiche WebLink
Waste Tire Survey & Inspection Report p p <br /> -siea Inspection Report Number <br /> rr Stete of MB18ll(Ornla Survey Form - Page 1 1 4 - 1 Q 1 3 8 5 <br /> CIwMe 787(New 0804) Y <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / D 8 � / - D Inspection Type (Fill one) <br /> Site Suffix: RoutineQ Re-inspection p Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: p/oQ <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address ) - l Sys(j A; 1 <br /> Inspection Date 03 <br /> J Z 07 <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> O PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) / 9 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' r / S Active ®Passenger ®Generator ®Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer 0 Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived 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 /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB x » <br /> 7E 4+4 ✓ <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days x�v <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities `NO Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators % <br /> Q Q Other: § L xx " ' tt, <br /> Comments _ t bs� 'P A4 itc�A'� „/� ��Loa/� GfJQJ <br /> co ao4d 9//x/06 y4r 6-2 wry Ali, <br /> Inspection Form Included:Q <br /> Comments Included: <br /> But;in s 's Sig6atufe Phone Number Inspector's signature. Phone Number:' <br /> INSTRUCTION O ACK ~f3 E Ax L,p E 2 62081 <br /> ■ White Copy COMB Yellow Copy.Operator Pink Copy.LEA ® ■ <br /> 0710204.0205 <br />