Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> Survey Form - Page 1 I $ - 1 4 0 7 0 7 <br /> CNVM81t11 gNew D4IW) <br /> CalHornia lnlegrated Wa to Management 11-r0 <br /> PartA-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details — <br /> TPID I b 3 y - Inspection Type (Fill one) <br /> Site Suffix:- - ®Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local (1_ If Referral,choose referral type(Fill one) <br /> Identifier: `�(F� C 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By In clot <br /> pM eQ s '�� C , TPG q _ <br /> Physical Address <br /> o,5 35 S N. [� - - - <br /> Af ((�5,q0 Inspection Date D -I <br /> tl 0�( Time In Time Out <br /> Business Rep n' D Title <br /> ��q � 0 AM 0 AM <br /> v N l /v Uri hGL I� 0 PM O PM <br /> Operational Status Tire Type Business Role Storage.Type <br /> Tire Count(Whole/PTE) (Fill one only) (FII all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O ®Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader-ODismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ®Other / <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 10 1 Other: § <br /> Comments + i -,� e y 7 p <br /> tY vi 71,E(W 1,��O�. <br /> n ,,1� *-M i <br /> 0 ,9�Ca.�la. r� <br /> ,Inspection Form Included:0 <br /> Comments Included: esRep!'s Signature <br /> �b- in I oes geute 0 Bus oe g <br /> Phone Number. <br /> ■ <br /> E R M p E11121-31 .62081 INSTRUCTIONS ON BACK ® ■ <br /> White Copy,CIWMB Yellow Copy Operator Pink Copy.LEA <br /> 0719--W4.0044 <br />