Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> 9tateelCalilornla <br /> C (NSurvey Form - Page 1 1 3 - 1 0 1 3 2 1 8 <br /> IWM181 ew 041041 <br /> Calllornia Integrate8d Waste Management Board <br /> Part A-Survey _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspectloh Detalls <br /> TPID- ' n n Inspection Type (Fill one) <br /> Site Suffix: ! l S - Q 1 <br /> ®Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier. Sa b'_ -0OL <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name -- - __ <br /> Inspected By Inspector <br /> B00-f <br /> Physical Address <br /> i -if33 67Aia1), <br /> �S <br /> Ca-(/'CT-k l C' 53,;L <br /> L) Inspection Date 01 <br /> y Time In lJ Time Out/ <br /> Business Rep Title O AM O AM <br /> �l Ol1/I�� S O PM O PM <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 /> ' r o Q Active Q Passenger Q Generator Q Outdoor <br /> O ®Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude _ Q Planned O OTR Q End-Use Q Container <br /> Business type (Fin — <br /> all that apply) � <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler 0 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 10 Other <br /> Part B Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility 1 <br /> MEMO <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 t <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 1 Q 1 Other. § t <br /> Comments jns poxG1LtJe .7AZs �q e does /'LO <br /> Wcf t� �tYY s OP ati&n 5latus for jl-3''e ro/OQYam y <br /> Inspection Form Included: <br /> Comments Included �OBusines�Ilgnm..­ oeoneum� .I Slna Phone <br /> Number <br /> ■ INSTRUCTIONS ON BACK E X AM Pit E 1 1111 <br /> s2081 <br /> White Copy.CIWMB Yellow Copy:Operator Pink Copy.LFA. ® ■ <br /> C171718194.0176 <br />