Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of <br /> ClWM Survey Form - Page 1 1 6 1 0 1 3 9 <br /> CIWMB 181(New 1g4) <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business.Profile Inspection Details <br /> TPID• I I r Inspection Type (Fill one) <br /> Site Suffix: 0 Routine O Re-inspection O Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: a4_1- or,ll<tk'Ly1 C � O CHP Q CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility Name 7\ <br /> YALE- P4c�FIC, Inspected BY Inspector <br /> Physical Address 3 19 - � 0 � 1� . D,, - Z <br /> X33 -I*f CGC'Cj" �C _ h�+� <br /> SI_ k_� CI^ C7-5a I Inspection Date <br /> r(x l/r Time In Time Out( �J <br /> Business Rep Title Q AM Q AM <br /> T,9m Fl ares / ,t Jm" / — 0 PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(W hole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f f v ®Active O Passenger ®Generator O Outdoor <br /> 0 O Closed O Altered <br /> GPS Latitude (a Hauler 0 Indoor <br /> 0 O Inactive O Truck <br /> Longitude - O Planned OTR ®End-Use ®Container <br /> Business Type (fill all that apply) r <br /> O New Tire Dealer O Auto Repair O Trucking Fleet O Government ORstreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer O Collection Q Crumb Rubber <br /> O Service Station O Hauler O Agriculture O Shredder if Other Rrk)jr¢ Sa�QS ' ii✓' <br /> I <br /> Part B Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENr0RCdM—M—yW1i 5" <br /> IS --' I I/�l1LiN APt 11fIA1dlEST f+�Efltllt2ElUtENTS <br /> O O PRC§42951-Waste Tire Hauler Registration andTransport of Tires — O.Notice Of Vlolatipn Q'.BXtenS9oat <br /> PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> O O _CQui Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle M <br /> 14 CCR§18459 -Responsible Entities Complying with Manifesting RequirementsDate m / Ia <br /> O O . <br /> 14 CCR§16459.1(a)(b)(c)-Tire Program ID Number from CIWMB - r. <br /> O O 114 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days lRegt+rred for NOV RIFXI) <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years ' <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators i <br /> O O Other: § <br /> Comments <br /> and sserv; ane na_w � alp m ak - <br /> IY)rb(rs+a l oca 'ori. To) C. reevtwY S i_ '52s 1. Ny-n-fi Qty N hZIER- Rer- L/'V r' <br /> y vi"twed.Aip 4--.s W;11 bL sen i ct d 6 q1 Z'5 S�k '11-Fic-flwe, Ak V iso ll s, <br /> Inspection Form Included:O � *jlgnaturs <br /> Comments Incl ��Business s Signatu PhoneNumber Phone Number <br /> ■ INSTRUCTIONS ON BACK 1IEIX1AjMjPjLji 1 2 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0 t".249 A4,Aj ;i <br /> ELLE COPY <br />