Laserfiche WebLink
a <br /> WMWaste Tire Survey & Inspection Report Inspection Report NumberStB1allfornle <br /> Survey Form - Page 1 I - 1 0 4 $ 1 7 <br /> CIWMB 181(Now 04104) <br /> California Integrated Waste Management Board <br /> Part A- Survey- _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> j TPID- kk Inspection Type (Fill one) <br /> Site Suffix: 1 o Ct 1 p , ® 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 <br /> Inspected By Inspector <br /> Physical Address <br /> o v-5 l�,,"" 4`W l 1 rf�L't• t <br /> S{-o r�"��vdt^ Inspection Date o <br /> Time In Time Out <br /> Business R1ep� ` TitleC O AM Q AM <br /> O PM O PM <br /> Operational Status The Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 1 4 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active ® Passenger 0 Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude I Q Hauler a Indoor <br /> Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container Iy <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer If Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body ® 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 /> I i <br /> Q Q ;PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements ` <br /> ',''� <br /> Q O - --- <br /> 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB _ <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days ' .,-__ <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years /f cyi• z 4z _: - <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 <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q 1 Q 1 Other: § <br /> Comments JtA -- <br /> l <br /> �. 0 V 1 DVl <br /> Inspection FormIncluded: Q � <br /> Comments Included: - - - - — <br /> Q4nessil Sl ature Phon Number Inspecto s Signature Phone Number <br /> INSTRUCTIONS ON BACK ✓/ 62081 <br /> �. <br /> CKA � PTJ7 f 23 <br /> White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA <br />