Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report NumberState ■ <br /> r ClWMf Callan I Survey Form - Page 'I 14 - 1 0 0 8 0 0 4 <br /> CIWMB 1B1 New 04!04 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- qQ� - Inspection Type (Fill one) <br /> Site Suffix: ' Z / U , Q r Q Routine Q Re-inspection 0 Referral Q Observation <br /> Local 1 i If Referral,choose referral type(Fill one) <br /> Identifier: Gctr� 4 G�qy Int�,� �-�, "�/'�/ Q CHP 0 CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ; Inspected By Inspector <br /> Physical Address <br /> IF <br /> Inspection Date O / n 9 <br /> Time In Time Out — T <br /> Business Rep Title O AM O AM <br /> 0 P 0 P <br /> Ll J 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 /> t t ® Active is Passenger Q Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude t, Hauler Q indoor <br /> o Q Inactive Q Truck <br /> Longitude - o End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Hauler Q Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility NFQRG MENT STATUS <br /> : V A HAULING AND MANIFEST REQUIREMENTS <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of Vlnlatloh Q`0011i114ft <br /> 0 Q PRC§42953-Contracts with Registered Waste Tire Haulers. Cotnpllence Distldlin, <br /> 0 Q PRC§42956-Registration/Decal in Vehicle <br /> 0 1 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date / I <br /> 00 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB EE <br /> - 1 <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (RQquMBtl fptuOf> <br /> 0 0 -- - - . � <br /> 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years � <br /> Q o 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Rehrf+�dJ �at �. %� '. <br /> Q o 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q o 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 11< FtIII�►x4ry�r% <br /> .ix ' sf iii wm. <br /> y. y^ , <br /> 0 0 I Other: § <br /> Comments <br /> o Ks 11 Ile, /0z)!5 ka p+ C) .Si' t2-_ <br /> Inspection Form Included: Q <br /> Comments Included: Q ,�('#"J/jt �e <br /> �us 4p #e Phone Numberspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Corn .gr eat: M A ,µ P LFE t j Z s2os1 <br /> White Copy' Yellow Copy Operator Pink Copy:LEA <br />