Laserfiche WebLink
092SSGSB877 <br /> IVIIIIII. Waste Tire Survey:& Inspection Report. . Inspection Report Number <br /> �� State of California " <br /> CiwMB 181 e ) Survey Form - Page 1 I 1 - 1127589 <br /> California Integrated Wastst Management <br /> Waste Management Board <br /> Part A-Surve - BLUE OR BLACK INK PEN <br /> Business ProfileInspection Details- <br /> TPID- ' � , - d 1 Inspection Type (Fill one) <br /> Site Suffix: `J ®Routine. Q Re-inspection Q Referral 0 Observation <br /> Local�01 n !bin If Referral,'choose referral type(Fill one) <br /> Identifler:. UJB ` ) l• Q CHP Q CIWMB Q Complaint .Q Educational Visit Q Other <br /> Business or Facilityarae <br /> c r ^ Inspected By Inspector <br /> Physical Addp&ss 1 1 U I� L <br /> Inspection DStreet <br /> ate 415 <br /> �ifyj_R _ State ZIP Code Time In Time Out —_ <br /> YU <br /> I Business Rep Title . IQ PM I � ® M <br /> 0 AM <br /> �� .JJ <br /> a� <br /> C— _ ` ----J L.S�- Operational Status Tire Type Business Role Storage Type <br /> t (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) : <br /> ^+ ®Active 0 Passenger Q Generator Q Outdoor <br /> Latitude � �1--- -- O O Closed Atere <br /> d W/A <br /> GPS 0 Inactive Truck Hauler Q indoor <br /> Longitude I I j { I I i Q Planned 0 OTR 0 End-Use Q Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer Q Auto Repair O Trucking Fleet Q Government Q-Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer ' • Collection Q Crumb Rubber <br /> 1 <br /> Q Service Station • Hauler Q Agriculture Q.Shredder Other <br /> Part B- Inspection of Waste Tire Dealer; Generator,.Hauler and.End-Use Facility ;EiVfORCEME T$TAj13; � 'Ri <br /> A �AULiNGwAND MANIFESTREQUIREMENT t - QfV Of ,F.xte�$ <br /> O O "PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 4 Ytola n bn <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. G mPlianced ne <br /> O O PRC§42956-Registration/Decal in Vehicle t <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB N <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred 1 C14YMB tEnftrcement <br /> 0 Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities wr <br /> O 0 '14 CCR§18462-Manifest System Requirements for Tire-Dealers or Waste Tire Generators <br /> �In Compl ance„t No 1/fiolatlons <br /> Q Q Other: § _ <br /> Commentsf i - <br /> �ZD- \ <br /> -4v-nS -�14•• � - <br /> �its. <br /> Inspection Form Included: Q{� - qpe �s <br /> Comments Included: 1111111 —Business R ps na ure Phone Number' InsSignature one Number <br /> 62081 <br /> INSTRUCTIONS ON BACK C •.ect . Iricorrecta E •l1 M P L E 1 2 3 = <br /> ■ W hi e C CI MB Yellow Copy.Operator. Pink Copy.LEA <br />