Laserfiche WebLink
tS3_ <br /> Waste Tire Su y & Inspection Report Inspection Report Number <br /> 1�Ik State of California <br /> CIWMB <br /> grated Waste <br /> eManag) Survey Form - Pdge 1 1 8 - 1 0 2 5 0 0 3 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / Inspection Type (Fill one) <br /> J <br /> Site Suffix: , J 76 15 - 01 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: � ,�- -f� Fob Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address . 5 <br /> �� Inspection Date � � ' � e�. I ('-j � <br /> ' <br /> Time In Time Out <br /> Business Rep Title 0AM 0 AM <br /> Pi i 0 PM 0 PM <br /> Operational Status Tire Type 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 /> a Active ® Passenger a Generator • Outdoor <br /> C Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> o Q Inactive a Truck <br /> Longitude - Q Planned Q OTR Q End Use ®Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q 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 /> i a <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other ���,� <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENrbRCI„MENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> Q Q Q t�ptlae Of Violation Q Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers, C04114 Deadlipe <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date< I L I L11 <br /> Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days ( .qulr9d fgrNOV orEXT) <br /> Q 14 CCR 18459.3- Retention of Manifest Forms and Tire Tri Logs for 3 ears -s <br /> t'J § p 9 Y s• .�-« <br /> Q Q 14 CCR§184602- Manifest System Requirements for Registered Waste Tire Haulers 1C W108- Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End Use Facilities y> i <br /> T_ _ <br /> Q Q 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ` F <br /> jatltpilnce I. No Violations <br /> Q Q Other: <br /> /§/� n _ r�., [ _ <br /> Comments 1 LGtvllf( `7TLFSO t�"-5f 7�. �1�s 1�q- 9-5 y USS i L��S'�c7�J <br /> % <br />