Laserfiche WebLink
M jiWaste Tire Survey & Inspection Report Inspection Report Number <br /> State of Callforria ■ <br /> CNmt*dlw l"VArl g Survey Form - Page 1 1 7�- 1 0 1 31 3 0 <br /> Glifomla Inlagntad Waw Management Board <br /> PartA-Survey _ BLUE OR BLACK INK PEN <br /> — — — — — <br /> Business Profile Inspection Details— <br /> TIMID- Inspection Type (Fill one) — --� - - - <br /> SRO Suffix: I 0 Z_ 4 4 (� r0 Routine <br /> Q Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier �-T^ � �yn Q CHP Q CIWMB Complaint <br /> __. O P Q Educational Visit Q Other <br /> Buslness or Facility Name - -- - -_ _ <br /> P <br /> I , , Inspected By Inspector <br /> �fY�-� � S� 0 4-`T�4- � � <br /> Physical Address <br /> Ad <br /> Inspection Date <br /> 04 / <br /> y Time In Time Out / <br /> Business Rep Title O AM O AM <br /> O PM O PM <br /> Operational Status The Type I Business Role Storage Type. <br /> The Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r ' <br /> 0 Active QPassen Passenger <br /> ®Generator 0 Outdoor <br /> Closed Q Altered <br /> �►Ps Latitude O 0 Cl0 Hauler 0 Indoor <br /> O 0 Inactive Q Truck <br /> Longitude - Q Planned 0 OTR 0 End-Use 0 Container i <br /> Business Type (Fill all that appy) - - - <br /> QNew Tire Dealer Q Auto Repair Q Trucking Flaet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection Q Crumb Rubber <br /> Q Service Station 0 Hauler 0 Agriculture 0 Shredder •Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility J n <br /> Q O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> OQ. PRC§42956-Registration/Decal in Vehicle 7 <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O O 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIW MB <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> "tea <br /> O Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> O 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 /> 010 Other: § <br /> Comments 6;r+ter AGO.— _ 9Y I a Q <br /> L� L^ <br /> pir,kn _" <br /> h__wos` , /T7hGs -T�D._ <br /> Inspection Form Included:Q <br /> Comments Included:Q . � %/1'� ) <br /> _ BUsln9as 's Si Signature Phone Number 4e.Signature ' Phone Number <br /> ■ INSTRUCTIONS ON BACK E X II M P L E ! 7 3 62081 <br /> White Copy CIWMB Yellow Copy.Opsr8tor Pink Copy:LEA ® ■ <br /> 0711604.0141 <br />