Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CfWMB Waste <br /> eManage Survey Form - Page 1 1 6 - 1 6 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN_ <br /> �Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site suffix: l 3 0 / / �/ / Routine Q Re-inspection Q Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit O Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address ( --:;5 <br /> 77 Inspection Date C.) <br /> Time In Time Out . <br /> Business R Title C)AM Q AM <br /> 0 P 0 P <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/'PTE) f t Q (Fill one only) (Fill all that apply)I (Fill all that apply) (Fill all that apply) <br /> ®Active O Passenger •Generator Q Outdoor <br /> 0 0 Closed O Altered <br /> GPS Latitude O Hauler O Indoor <br /> O Q Inactive Q Truck <br /> Longitude - O Planned Q OTR O End-Use O Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet O Government O Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body 0 Car Dealer O Collection Q Crumb Rubber 124w Q Service Station Q Hauler O Agriculture Q Shredder Q Other e' l <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility f gNFORCEMENT STATUI3„.h w <br /> V i41 HAULING AND MANIFEST REQUIREMENTS Notice.Of Vigi tion Q xc�t }fit <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires ✓�j <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance D64011ne 1-5-4 <br /> 0 O PRC§42956-Registration/Decal in Vehicle ��. <br /> O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements p6to M <br /> O O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O j O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs Within 90 days (RaquketliorN[#1( <br /> f <br /> 0 014 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> /aw <br /> O O 14 CCR§18460.2 Manifest System Requirements for Registered Waste Tire Haulers O Refafred rCIYYIII �ntfls � <br /> 0 O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities s <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O OOther: § <br /> L >/ <br /> Comments- C-a- ,t,r c ,9AV5 01414- <br /> A <br /> `✓�"ir � <br /> a /el- <br /> l; <br /> Inspection Form Included: Q - <br /> Comments Included: Q - '` — - 3 70S <br /> Business Rep's Signature Phone NTumber pec gn Phone Number <br /> _.....-. ...... .... ............_. <br /> INSTRUCTIONS ON BACK `Correct-* Incorrecdt� , ( E M p � � � 2 � s2oe1 <br /> ■ While Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />