Laserfiche WebLink
;.- Waste Tire Su. :y & Inspection Report• Inspection Report Number <br /> State of California <br /> Cgrated Waste <br /> eManag) Survey Form - Page 1 I6 - 1025686 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Detolls <br /> TPID- Inspection(� CC II Inspection Type (Fill one) <br /> Site Suffix: 1 _'] � } `D � 1 � l ® Routine O Re-inspection O Referral O Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: To ✓t 0'(71/tj� <br /> O CHP O CIWMB O Complaint O Educational Visit Q Other <br /> Business or FacilityName <br /> Inspected By Inspector <br /> C0Ker.24+e �-►�C. ) <br /> Physical Address — ! -Q(JI,L l.t `�L4_t <br /> '7q9 Sa&,� <br /> CA /����� Inspection Date <br /> " Time In Time Out <br /> Business Rep /� Title O AM O AM <br /> NQr mciii " " �V�j� nate_t 11 1�� O PM O PM <br /> I Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apps (Fill all that apply) (Fill all that apply) <br /> /((7 ® Active Q Passenger ® Generator 0 Outdoor � <br /> O O Closed O Altered 4 <br /> GPS Latitude O Hauter Q Indoor <br /> � 0Inactive ®Truck <br /> Longitude — O Planned O OTR O End-Use O Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuei <br /> 0 Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture O Shredder # Other umejLt �y <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility �. NF� MNTT TATUS _ <br /> =V A:` HAUfIN+4 AN1�MAI11=6T.ftEQUIRMN f6 <br /> O O V;fQlat(on 0 Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. co i DoadI e <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> t. <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> DON <br /> 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days I gYked fot NOV or EXT) <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 I J WNV! nfprCetiletlt <br /> O O 14 CCR§ 18461 - Manifest System Requirements for Waste Tire End-Use Facilities _ <br /> 00 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators .Y <br /> > �� <br /> #�fA iil�tpttpna _t <br /> O O Other. § <br /> aComments <br /> �F�-CktC-11!!�) ir;JJ rZ>Of- 0V' .preLvj VWn �_rIV f CYta <br /> lv�_Q__ trctCkl <br /> *ofi Ie- -<,Cryju ✓tewed <br /> a_.t <br /> Nv <br /> OInspn Form Included*. <br /> Included: 0 <br /> eComments <br /> Business Rep'snature Phone Numbe-r� pector's nature Phone Number <br /> INSTRUCTIONS ON BACK �069-� ���?���►h �L� 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />