Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Slate of California <br /> CLIMB Waste Management <br /> Survey Form - Page 1 1 8 - 1 0 2 8 7 8 2 <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Q Inspection Type (Fits one) <br /> Site Suffix: .0 Routine Q Re-inspection Q Referral Q Observation <br /> Local 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 .Inspected B <br /> �. P Y Inspector <br /> ..wt.r�` .� c� ! <br /> hicaf �Address 1� 1 l C7 / — <br /> Inspection Date rj <br /> C� / . / `j <br /> to ��-31 <br /> ` Time In Time Out <br /> Business Rep Title O AM O AM <br /> 0 PM Q 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 thal apply) <br /> t.Active IS Passenger ® Generator 40 Outdoor <br /> � Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive ®Truck <br /> Longitude — Q Planned Q OTR O End-Use t♦Container <br /> Business Type (Fill all that apply) l <br /> o New Tire Dealer 0 Auto Repair Q 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 /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFgt1S TIENT STATUS <br /> _ . _ <br /> V A HAULING AND MANIFEST REQUIREMENTS i Q NdWo(NOt Vlo(atldn Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. COnpaltiptl;:Deydlln <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements I 'Date <br /> O O 14 CCR§ 18459.1 (a)(b)(c)-Tire Program 10 Number from CIWMB <br /> 'S> tjguftdPorNOVorEXE <br /> O O 14 CCR§18459-2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days t a, <br /> Q O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years ; <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers ' t "It:IWMill Enforcement <br /> �- <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators f atxcs �'Np Vlalatl4tts <br /> O Q 1 Other: <br /> Comments W OL% <br /> Acpje.r- Ind Is <br /> r"_6 Y5c r� v� av�. s �•n <br /> \A'-4V rcs��& ,r <br /> Inspection Form Included: <br /> Comments Included: Q <br /> ���� X53 7eslg <br /> Business Rep's Signature Phone umber In re Phone Number <br /> 1 -T r — 62081 <br /> INSTRUCTIONS ON BACK Corrgt' 'IttcorClE1;_ lv' i A �_P` _L'1 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />