Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Clate of WMB1all(Now Survey Form - Page 1 1 7 - 10 1 4 8 8 8 <br /> CIWMB 181(New 04104) <br /> California lntsagrated Waste Management Board <br /> Part A. Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I Inspection Type (Fill one) <br /> Site Suffix: I 3 7 / / 0 Routine 0 Re-inspection 0 Referral 0 Observation i <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �i� �r.C ,. C�� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> C� Inspected By Inspector <br /> PhysAddressr <br /> - ��� <br /> Inspection Date 'v 2— <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> > 1 0 PM 0 PM <br /> :!ey_ 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 that apply), <br /> 1 ' ® Active ® Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck i <br /> Longitude - 0 Planned 0 OTR i 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 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body S Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility 15NQRENT`BTATU3_____�T___ <br /> =A i HAl[(ttNOAN[�MA(i KST REQUIRRIll FS - - C1RM <br /> 1 <br /> 0 Notice Of Violation Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Slflki{7��fiR9:pe8dllne: <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 00 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirementsp ' / <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 flAurtgd fOrN01/grFX7) <br /> '; <br /> 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 ) �i�nTDtQOT119f1t _ <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 v <br /> 0 <br /> Comments <br /> t�'if�-fv,,•�1 C f�;w�.-- L�;t,�� r s 1��I, �� was->�.= ►^�-� <br /> -�=r�l- 7 <br /> G i / N fr✓`E� (�j Pr CJ� q hG.0 t s lC Yea h��y^� <br /> Inspection Form Included: 0 <br /> Comments Included:0 - -BusinessRep's S nature Phone Number Ins p or's Signature Phone Number <br /> INSTRUCTIONS ON BACK I �-} /, �',X A!;d�4 E� 3 62081 <br /> P <br /> White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA <br />