Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report Number <br /> r State' California Survey Form - Page 1 1 2 - d $ 01 0 <br /> C1WM6 181 stew a <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Detells <br /> TPID- D t Inspection Type (Fill one) <br /> Site Suffix: 0 a t) II 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local if Referral,choose referral type(Fill one) <br /> Identifier: i Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> �a&, \\ -s � vrZ,��s Sexv 1rQ 1 <br /> Physical Address <br /> 5550 <br /> Inspection pate <br /> �T�>n Time In Time Out [[ <br /> Business Rep Title O AM O AM <br /> 0 P 0 P <br /> i Operational Status i 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 /> f f IIs Active 0 Passenger Q Generator Q Outdoor <br /> � 0 Closed �Altered <br /> GPS Latitude 0 Hauler Q Indoor <br /> C Q Inactive Truck <br /> Longitude - Q Planned OTR O End-Use 0 Container <br /> Buslneas Type (Fill all that apply) <br /> Q New Tire Dealer Q 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 0 Collection Q Crumb Rubber <br /> Q Service Station 10 Hauler Q Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility IRMO <br /> 14AIN4DMA8T_RQY .A. ULJIREM6NT8 <br /> O O O Mattco (�Il�fia�r } x <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires / <br /> / T <br /> PRC§42953-Contracts with Registered Waste Tire Haulers. / <br /> O � O 6gmiiltitsi�'4 <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements (pip r <br /> 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB Y <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days T��;'/ � <br /> Q O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O j 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> 14 CCR§18461 - Manifest System Requirements for Waste Tire End-Use Facilities ' j�J/�,��'��/'•c�'��� � � /� <br /> Q 1 Q 114 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Yz/ <br /> O O j Other: § <br /> Comments / (1 ,�-d` �.�'�"�c- '1Y\S�e Tlc'`�+n rjLtr- r'C Gk W0-r"-'- \A.tAGtC <br /> �e J oLA— 0-z.7 Z D Ltc- t''1k -� 36 5E?-k . <br /> Inspection Form Included: Q <br /> Comments Included: Q `�'�/� -Og��753 76P8 <br /> Business Rep's Signature Phone Number I lazir ature Phone Number <br /> INSTRUCTIONS ON BACK Q 1Fi cidJ E.X ,- P p 2 3 62081 <br /> While&py:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />