Laserfiche WebLink
Waste Tire Survey & Inspection Report -lnspectionReportNumber <br /> ■ 16a <br /> etata or Calfaornfa Survey Form - Page 16 - 1006372. <br /> CIWMB tea(New OA/od) <br /> CalHomla Integrated Wasta Management board <br /> Part A-.Survey BLUE OR BLACK INK PEN .. <br /> Busln4ss.Profile Inspection Details: <br /> Tplp_ � _ 1 — ` Inspection Type (Fill one) . <br /> Site Suffix: O � 1 ` ®Routine Q Re-inspection Q Referral Q Observation <br /> Local (�+ ( If Referral,choose referral type(Fill one) <br /> Identifier: a1N:5t,a1""t r` t�W�'C�1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name u I Inspected By Inspector <br /> \1r.c-e�� `�V 1�' <br /> Physical Address <br /> �1 <br /> CA <br /> ` q55_ <br /> _ Inspection Date <br /> Time In Time Out <br /> Busing !Rep k Tide Q AM g 0 AM <br /> �h a� ,M d 3 O PM 1 J 0 PM <br /> wk- V"— Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (FIIL all that apply) (Fill all that apply) <br /> I®Active to Passenger ®Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler ®Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use 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 /> i®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 <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 <br /> .0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIW MB }' <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days p <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 <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities 4 <br /> tQ Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O 1 Q <br /> Other: <br /> comments l5 �Wn��(�7 ��pw� 51CM L.S-f-S Sa <br /> T _I`_ � , <br /> `c`.. w-C' pv�- S ��r-< 1u <br /> Inspection Form Included:Q �p ppr�y! pp <br /> Comments Included:: " *}� <br /> jess Re ignature Phone Number Jnsp ctor's Signature Phone Number. <br /> 62081 <br /> INSTRUCTIONS ON BACK E ?G A h P L E 111213 <br /> ■ While Copy CI W MB eYellow Copy:Operator Pink Copy:LLA '■ <br /> 0529204. 1047 <br />