Laserfiche WebLink
U�.11tJll�til�il <br />t Waste Tire Sulky & Inspection Repo Inspection Report Number <br />cea_ - <br />lI�I{i State of California <br />Integrated ast<eMaage Survey Form - Page 1 I 1 10880 6 5 <br />California Integrated Waste Management Board <br />Part A - Survey' BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />TPID - Fk <br />1�11 <br />-Inspection Type (Fill one) <br />Site Suffix: 3$ a, o ®Routine Q Re -inspection Q Referral Q Observation <br />Local I �nydn,� un <br />Identifier: Co <br />Business or Facility Name <br />If Referral, choose referral type (Fill one) <br />Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br />Inspected By <br />Inspector <br />Phy��Yi�t_w_11e�15h]sical Address <br />Street <br />of J� Inspection Date <br />L <br />City Slefs C ZF Code i Time In Time Out <br />Business Rep Title F % j , F_L ! O AM ; �h ® AM <br />® PM L�l— ' i ✓ 1i of O PM <br />-_ iraY, �� MaUT-0 -_— - -finer <br />Operational Status Tire Type Business Role Storage Type <br />The Count (Whole/PTE) (Fill one only) (Fillmall that•apply) (Fill.all that apply) (Fill all that apply) <br />D I® Active ® Passenger Generator ® Outdoor <br />0 Q Closed Q Altered <br />GPS Latitude Q Hauler Q Indoor <br />_ Q 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 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 />t <br />Q Service Station Q Hauler Q Agriculture Q Shredder ® Other i&LA\eel <br />l �— P�- <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />Q <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q <br />.14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q <br />Q <br />14 CCR § 18459.1.- Tire Program ID Number from CIWMB <br />Q <br />Q <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />Q <br />Q <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q <br />Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />Q <br />1 Q <br />1 Other: <br />Comments RL- <br />nspection Form Included: <br />Comments Included: Q v� <br />Business <br />INSTRUCTIONS ON BACK <br />0 <br />Phone Number <br />White Cop} CIW Mq' Yellow Copy: Operator <br />_. trvl cf Kj - 14L.- /_ > <br />ns a o <br />Ir's n ure . Phone Number <br />EJXJAJ MIPILIEI JIJ23 62081 <br />Pink Copy: LEA <br />