Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report Number <br /> es <br /> State CaliforniaSurvey Form - Page 1 1 4 1 4 4 2 <br /> CIWMB 181(New 04104) + <br /> California Integrated Waste Management Board <br /> Part A-Survey _ _ -- BLUE OR BLACK INK PEN <br /> Business Profile — Inspection Details _ --- <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: (jo 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 By Inspector <br /> r{ <br /> PhysicAl Address ` > <br /> Inspection Date ` p d ''� O �C dd <br /> �� -- Time In l Time Out <br /> Business Rep ( { ( Title O AM O AM <br /> O PM O PM <br /> '✓ Operational Status Tire Type Business Role r Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) I (Fill all that apply)' <br /> Active ®Passenger '®Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude _ Q Planned Q OTR O End-Use Q Container <br /> Business 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 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 Us <br /> 3: <br /> Facility KIM <br /> �am�{u�,,♦t <br /> Q O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires / 11 il� � ��� <br /> Q O 'PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> PRC§42956-Registration/Decal in Vehicle ✓% f :` ' % i/�J 1 <br /> 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB �`iay �i / <br /> 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O O <br /> 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q O 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 /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q O .Other: § <br /> Comment kSC U" ��Yew •0O fs"-�S' _ `�L'�cu S <br /> Xz <br /> t� t��- w �-t- �t vim_. u, •� �o w� ` Pal <br /> - . � •-� �_� ,��,�-,��. � 5� _ <br /> inspection Form Form Included: <br /> Comments Included-Q <br /> Business Rep's Signature Phone Number Inspecto' Signature _ Phone Number <br /> »y` ri i y,- i 62081 <br /> INSTRUCTIONS ON BACK /'~ `X3hlk P Y 3 <br /> While Copy.CIWMB Yellow Copy.Operator Pink Copy:LEA <br />