Laserfiche WebLink
=r Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State Or CaliforniaSurvey Form - Page 1 1 4 - 1 01 3 7 71 <br /> CIWMB 181 stew nage <br /> Califomia Integrated Waste Management Boa04) rd <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local (1_ n If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> 7-l,or�► Tri- 3 Cl - l 0 1 4� y� <br /> Physical Address <br /> 0 800 7—w►y� <br /> J���n /l^ Inspection Date O S J 07 / O <br /> ,4 q��t& Time In Time Out <br /> Business Rep Title ) o O AM O AM <br /> OKJ� ` D V S PM O PM <br /> Operational Status' Tire Type Business Role i Storage Type <br /> Tire Count(Whole/PTE) ' (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active Q Passenger ®Generator jP Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive •Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair .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 Q Hauler Q Agriculture Q Shredder Q Other <br /> i - <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q Q 14 CCR§18459.3-Retention of Manifest Fortes and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 010 Other: § <br /> Comments _ +YuJ _ 1Q1lfZ ..Was �-- <br /> ' <br /> yr � N���it ✓mss Vs fipm Dice <br /> a.. W-e. �T <br /> (. iYe /�Iy�,,tram cck , / Pt b" 0n v�eaV fZt Aad <br /> (h -. owk r 0D V 6) laWffS a <br /> Inspection Form Includ d: /95 � <br /> Comments Include --- 2,33 <br /> - — 9 <br /> Bu (ness Rep_'. Ignaturs _Phone_Number _ s ctor's St nature Phone Number <br /> INSTRUCTIONS ON BACK IEIXIAIMIPILIEI 11 2 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA ® ■ <br /> 0617904.0253 <br />