Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report Number <br /> StateCalifornia Survey Form - Page 1 1 9 - 1 0 10690 <br /> CIWMB 101(New 041041 <br /> CaliforniaaIntegrated ed Waste Management Board <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection I / - O I Inspection Type (Fill one) <br /> Site Suffix: 5 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ! e— If Referral,choose referral type(Fill one) <br /> Identifier. (C J�^'rn` �Or� / 'fir 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facili Name ��v` <br /> Inspected ey Inspector <br /> A- 1 a� <br /> The . 3 <br /> Physical Address <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> �O r U` �5�� D W 1ti2.r✓ O PM O PM <br /> Operational Status 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 /> Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O •Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Buslness 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 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 Registration and Transport of Tires 4 <br /> 0 0 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 }, <br /> 0 0 14 CCR§18459:2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> a <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> +r. <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 ` <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators- F�^ <br /> 0 0 Other: § a <br /> Comments i 4 11 I o <br /> f s <br /> 4k.s litre h_cut Q�tipiI or III `fo his <br /> _ lkis a 1 W_ al o cWAA lawn-liowier- <br /> Inspection Form Included: h[ <br /> Comments Included: <br /> Jilaefness Rep's Signature Phone Number In a toes slture Phone Number. <br /> INSTRUCTIONS ON BACKsp � E XT t . P ' 1 62081 <br /> ■ White Copy CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0f 11 E.4_14.A17 <br />