Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report Number <br /> State CIWMB California Survey Form - Page 1 1 7 - 10066121 <br /> CIWMB 181 stew 04104) Y 9 <br /> CdMomla Integrated Waste Management Board - _ <br /> PartA-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: G ®Routine 0 Re-inspection 0 Referral 0Observation <br /> Local If Referral,choose referral type(Fill one) - <br /> Identifier. 50LW5,,0k Co 0-4.4, 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> _ - - ------ (3 Inspe� By <br /> � Inspector <br /> ,-- <br /> Physical Address I q r <br /> 11 . nn AA ]A—i <br /> \ Inspection Date , I L> 1^ Sri <br /> O Ciw�O� _C Y. .[a` Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> L ®PM b '. - D LD ®PM <br /> OperationaLStatus Tire Ty <br /> f pe Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that.apply) (Fill all that apply) <br /> ° O ®Active 0 Passenger ®Generator ®Outdoor <br /> GPS Latitude oo 0 Closed 0 Altered <br /> Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned — 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill ell 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 /> I, x : ,., <br /> 0 0 PRC"§42951-Waste Tire Hauler Registration and Transport of Tiresa <br /> PRG§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 0 PRC§42956-Registration/Decal in Vehicle `• a� F• '-= ` <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 foci years <br /> 0 0 14 CCR.§18460.2-Manifest System Requirements for Registered Waste Tire Haulers s a <br /> 0 0 14 CCR§18461:Manifest System Requirements for Waste Tire End-Use Facilities : <br /> . 0O <br /> 14 CCR§18462•Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 0 Other: r' w <br /> Comments G4.0 W kcc.yn-t,t <br /> r- <br /> �z i�f.k-� T 5 - <br /> ,.�r,�\-�c.. T'�w�, a-cu,• �_tf„ �- �� ��tt t�- 'ih) ill a-t:�.c���ay�.� r �,f-,.�sx,o <br /> "o <br /> r�" 475;-7%1 <br /> Inspection Form Included:0 <br /> Comments I Business Rep's Signature - Phone Number Ins btbr's Slgnaturer. Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK <br /> ■ White Copy,CIWMB Yellow Copy.Operator Pink Copy:LEA ■ <br /> 0525804.0144 - <br />