Laserfiche WebLink
�l Waste Tire Survey & Inspection Report Inspection Report Numberstate ■ <br /> CrWM8f California Survey Form - Page 1 13 - 1 013606 <br /> CM1 ate 181(New nage <br /> California Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / S 5' q I Inspection Type (Fill one) <br /> Site Suffix: 3 O 3 Routine Q Re-inspection Q Referral Q Observation <br /> Local H If Referral,choose referral type(Fill one) <br /> Identifier: G1Q�Gul Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address - ['"4BDy/t//*-oYA <br /> Inspection Date <br /> C-� 7 Time In Time Out <br /> Business Rep Title [/ p AM f} AM <br /> 0 PM l ✓ / 9 0 PM <br /> — <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 /> t r Q 0 Active Q Passenger 0 Generator 0 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive ®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 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 n I <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 0 Other Strrap 00)'e .0 ,C _ei3pe4wk <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility d <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <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 /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q Q 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 <br /> Q Q 1 Other: § <br /> Comments �_L2�I c-�P �lJ� a'f'oe �'�c li g e--5p <br /> Inspection Form Included:Q <br /> Comments Included:Q z 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number _ <br /> INSTRUCTIONS ON BACK 1EjXjAjMjPjL 1. 2 62081 <br /> ■ While Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0617904.0412 <br />