Laserfiche WebLink
t , Waste Tire Survey & Inspection Report Inspection Report Number <br /> Stale of California Survey Form - Page 1 1 4 - 1 0 1 0 8 0 2 <br /> cnvMa tat tNew oaos) <br /> c'IIfzla;t gratad Waste <br /> Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details J <br /> TPID- / D / 7 - O / Inspection Type (Fill one) j <br /> She Suffix: O 0 Routine Q Re-inspection 0 Referral 0 Observation <br /> Local ' If Referral,choose referral type(Fill one) <br /> Identlfbr. I/t_ tYda�Glw77 0 CHP 0 CIWMB 0 Complaint. 0.Educational Visit 0'Other <br /> Business or <br /> Facility Name Inspected By Inspector <br /> Physical Address 3 <br /> Inspection Date S rO g / 7 <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 0 PM 0 PM <br /> perational Status TireType Business Role storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply)I (Fill all that apply) (Fill all that apply) <br /> r a Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ID Other Caerst.cP E •�" <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 14 CCR§16459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 1 0 1 Other: § <br /> Comments �LZGir G' 4Ve7 W A 1,e4"vv,yy, cs�� p"j%^ta. G�*."i2e rzir.,a..t <br /> 9 ��wg►vt 14',ky 4,-t Ac-0,i M4*2,— 7ft�e .4-►4 --le <br /> ,�IQtey�i7"�1` tisl e Co.,•►! ,fir act a,.. .4-oke <br /> 06/1-�7 4-p4e-e use <br /> Inspection Form Included:0 <br /> Comments Included:0 <br /> Bus ss Rep's Signature Phone Number Inspector's Signature. Phone Number <br /> INSTRUCTIONS ON BACK @ 31E1XjAjMjP1L[Ej. .111213162081 <br /> ■ 0716504.0035 White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />