Laserfiche WebLink
E0 <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California I / 1/'t' I/''�I t/''{� ''�j <br /> w OVO4) <br /> California IntegratedCIWMB tWas W81 aste agement Board Survey Form - Page 1 1 I - 1 V V V L J - <br /> Part A.Sur BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details - <br /> TPID- D 0 - O Inspection Type (Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral. Q Observation <br /> Local If Referral,choose referral type(Fill one) .. . <br /> Identifier. . . O CHP Q CIWMB Q Complaint <br /> Q Educational Visit Q Outer. <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title Q AM 0 AM <br /> O PM 0 PM <br /> ✓tet{`-''•�!(�s(� Operational Status Tire Type Business Rale Storage Type _ <br /> Tire Count(Whole/PTE) D (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger Q Generator Q Outdoor . <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O 0 Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair I*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 /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> OWN •> "h tr <br /> Q %Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires r wy <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. q <br /> Q Q PRC§42956-Registration/Decal in Vehicle v <br /> Q Q 14 CCR§18459 -Responsible Entities Complying With Manifesting Requirements e <br /> Q 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 <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <§ r <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> . Q. 0. 14 CCR'§18461-Manifest System Requirements for Waste Tire End-Use Facilities �- <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators r. " <br /> Q Q Other. § ' <br /> Comments C'c�c.1�►'1'�._ <br /> S1yL aJld is AA e \ow.c+�v�C �czy C3 Cc'rr-�OCL�L <br /> Enterer <br /> KB <br /> Inspection Form Included:Q <br /> Comments Included:Q <br /> Business Rep's Signature Phone Number In ig Phone Number, <br /> INSTRUCTIONS ON BACK � � E. i . 62081 <br /> ■ White Copy.CIWMB Yellow Copy:Operator Pink Copy.LEA © ■ <br /> 0529204. 1176 <br />