Laserfiche WebLink
Inspection Report Number <br /> Waste Tire SAey & Inspection ReporState <br /> ClWM 181lCalifornla Survey Form Page 1 1 5 1 0 2 5 8 4 2 <br /> CIWMB 181 INew 04104) � + <br /> California integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile it Inspection Details <br /> TPID- R n i1 1 Inspection Type (Fill one) <br /> Site Suffix: !I a y { I I ®Routine Q Re-inspection Q Referral Q Observation <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 <br /> ' inspected By inspector <br /> ORCO Tire, C.121ki- . <br /> Physical ddress <br /> SSC, h,, �r�I u Inspection fate t1 / 1 ( / O ij <br /> J Time In V Time Out <br /> BusinessRep <br /> Title O AM O AM <br /> 0 P 0 P <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 /> Active ® Passenger 6 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude - Q Hauler a indoor <br /> O Q Inactive Q Truck <br /> Longitude - - Q End-Use Q Container <br /> Q Planned �OTR <br /> i <br /> Business Type (Fill all that apply) <br /> • New Tire Deafer Q Auto Repair Q Trucking Fleet o Government o Retreader Q Dismantler o 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 wENFORCEMBNT STATUS_.._ ; <br /> . Ali Hao NGI ANP M/�iI�IF�9�'>RfiQU1REMBAI'Ir5 - <br /> 00 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0.14 <br /> otlRa Of V101etloft o ta�rlelon <br /> 0 o PRC§42953-Contracts with Registered Waste Tire Haulers. �glt}{}Jttj`flCg tjgAdhr.9 <br /> 0 o PRC§42956-Registration/Decal in Vehicle m m m <br /> o 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> o 0 14 CCR§18459.2.1 -Submittaf of Manifest Forms and Tire Trip Logs within 90 days (05gg1md.Pr-NOV or <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O <br /> 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers pTIJWIIQ Hnfpra.' gnt y <br /> 0 0 14 CCR§18461 Manifest System Requirements for Waste Tire End-Use Facilities f ' <br /> 0 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 Lo Other: § n �/ /'�r' :... <br /> Comments -R S-�yed Ta LSA 1� l qeC�C" ��- !g � AudU.t�.S�S On- _Ij� <br /> {r_k_- 'ile5 I-WiCe Ct LVe-eg Oy, SI he_ ✓z� <br /> ?� y� ars- MID <br /> (Inspection Form Included: Q � f adZ12 e/ c __ p�,(� <br /> Comments Included: Q — s �/ L ���^l l <br /> tress Rep's Signature Phgne Number t4spector' Signature Phone Number <br /> INSTRUCTIONS ON BACK (I`itfC10" ,` ( 1 - 62081 <br /> I r �� L-"kit-r�,�PLL E1 112 3 <br /> While Copy:CIWMB Yellow Copy:Operator Pink Copy:LFA <br />