Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State o,California Survey Form - Page 1 1 1 . 10 13 0 0 1 <br /> CIWMB M(New 04104) <br /> califomia 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: ` 0 3 � ( 0 ®Routine Q Reinspection Q Referral Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ll� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected B <br /> P Y Inspector <br /> �CoC� lo�IS <br /> Physics Address 3 � - <br /> Inspection Date 09 <br /> X0 O 60 <br /> Time In Time Out <br /> Business Rep Tit e O AM O AM <br /> O PM O PM <br /> 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 ' 0 Active ®Passenger ®Generator 0 Outdoor <br /> GPS Latitude O Q Closed Q Altered <br /> Q Hauler Q Indoor <br /> D I Q Inactive Q Truck <br /> Longitude - Q Planned OOT Q End-Use 1 Q Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ®Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFQ(tM N't"STATUS <br /> JtNTS - <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle ` <br /> Q Q :14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> O Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB J <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Repulsed(Oc/YOV a_ X77 <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years - <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers ( eYiejh�Sil �l»ifppFRh60}Pjj <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities 3 <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators _r <br /> Q Other: § Wit, <br /> 1i� it3 �. ti0 VtialBbwa <br /> sr3 � s xt� y c ma <br /> Comments.�p„ �y��-yt_y�f41�1T1 rp�! Y�A.J�)��/�aL��'LLd� <br /> c sd jFrnm <br /> K0-_�/tD �VIS <br /> Inspection Form Included:Q C <br /> Comments Included:Q — JC(/ <br /> Business e ' SI atur Phone Number In tor's SI n lure Phone Number <br /> INSTRUCTIONS ON BACK �� m � X a JiA L Z 3 62081 <br /> ■ P'>XP.s^=r.�.n.. raape O..xa.+3. a ® ■ <br /> White Copy:CIWMB Yellow <br /> Copy Operator Pink Copy.LEA <br /> 0624904.0150 <br />