Laserfiche WebLink
I a Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CIWMa 18 <br /> asteManage Survey Form - Page 1 1 - <br /> Cellfomia Integratetl Waste Management Board <br /> Part A-Surve _ BLUE OR BLACK INK PEN.. <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site suffix: ! D <br /> 8 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S 001\} D "t� vow Q CHP Q CIWMB Q Complaint .Q Educational Visit Q Other <br /> Business or Facility Name - <br /> Inspected By Inspector <br /> Physical Addr s - (� <br /> \1� NI CAX53 Inspection Date <br /> Time In v Time Out <br /> Business Rep Title Q AM _ <br /> 1r, �AM <br /> k S S" t3 PM Z 4 5 ®PM <br /> �j �pvr(JV.O` Operational Status Tire Type Business Role Storage Type. <br /> Tire Count(Whole/PTE) 5� (Fill one only) (Fill all that apply) (Fit all that apply) -(Fill.all that apply) <br /> t ' ®Active (ij Passenger ®Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q inactive Q Truck <br /> Longitude _ Q Planned Q OTR Q End-Use ®Container <br /> Business:Type (Fill all that appy) <br /> ®New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ®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 /> :0 <br /> O O PRC§42951 'Waste Tire Hauler Registration and Transport of Tires x ` <br /> Q 1 Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q PRC§42956-Registration/Decal In Vehicle <br /> 0 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 }.. r. <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days ' <br /> Q ® 14 CCR§18459.3-Retention of Manlfest Forms and Tire Trip Logs for 3 years' <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> ' . <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities t �, <br /> �.. <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other. § ?a <br /> Eomments0- `✓ s toy t ae�, 6,7 <br /> oyN <br /> �Q'Ot.lti�C r► <br /> Inspection Form Included:Q ^ _ <br /> Comments Included:Q �� �47��0 401 '- S <br /> L. . Business Rep's Signature Phone Number Ms ctor's Signet e= Phone Number• <br /> INSTRUCTIONS ON BACK I EIXIAIMIPt-I El 1112-131 <br /> 62081 <br /> White Copy CIWMB Yellow Copy Operator Pink Copy:LEA ® ■ <br />