Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of B187(New 04!04)California <br /> CIWMB Survey Form .. Page 1 1 7 - 10 2 6 761 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ;Inspection� � � � � - Q � i Inspection Type (Fill one) <br /> Site Suffix: ` • Routine Q Re-inspection Q Referral Q Observation <br /> I <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 141a 6114 / <br /> Physical Address / :7/.o,,; ly <br /> �53 Inspection Date U 495 <br /> / O r Time In Time Out <br /> Business Rip Title 0 AM Q AM <br /> 0 P OPM <br /> Operational Status Tire TypeBusiness Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) 1 .7- <br /> 0 <br /> y ® Active • Passenger !Generator 0 Outdoor <br /> Latitude Q Closed Q Altered <br /> GPS O Hauler Q indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Reireader 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 ENFARGEMENT.$TATU, r <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Ngtla+d 0f'vtal8tion Q ftt� <br /> tr�fjpg�, <br /> Q O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Cgmpllane Deadline ; <br /> Q Q PRC§42956-Registration/Decal in Vehicle `` �X". <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date L I <br /> O O 14 CCR§18459.9 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 Submittal of Manifest Forms and Tire Trip Logs within 90 days (RPQG!ltsC�fClt 4./V(�1TD!1p. . <br /> Q O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q`i!f►f�l9red fI1�tCIlAlI ,C) X1 �� /. <br /> O O 114 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ani` <br /> O O _ - <br /> Other: § <br /> Comments 1-�1,7l- 'F 740.-/ <br /> 7*5 oC�v�C. G�1.� L✓t+Y <br /> /,V" r' ''"ony -� �rteicv�- <br /> CuG,�I Arc> Z.44i'7 //rte w1�6tc_ ��cs <br /> ('Inspection Form Included: Q' 75 -76 fs <br /> J Comments Included: Q - -- - --- --— -- <br /> Busi ess Rep's Signature Phone Number nsp t r' gnature Phone Number <br /> INSTRUC�NtRI�V BACK Corroct:`* -lncorrectt X-� A P L 1 1 2 3 62081 <br /> KB White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />