Laserfiche WebLink
;= Waste Tire Survey & Inspectid'h i boort Inspection Report Number ■ <br /> re: <br /> SlWIMB California Survey Form Page 1 13 0 08093 <br /> CIWMa 181(Now 041114) s <br /> California Integrated Waste Management board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile I Inspection Details <br /> _ I <br /> TPID- ,i Inspection Type (Fill one) <br /> Site Suffix: "� I m Routine Q Re-inspection Q Referral Q Observation f <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: <br /> .0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Phy�cal Addiless V V�v p `� — ` ` .���•ti`r,`t - <br /> � l <br /> Inspection Date � � � � � � fl <br /> u' v�^ Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM C) PM <br /> Operational Status I Tire Type Business Role Storage Type l <br /> Tire CountWhole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)I <br /> t r to Active I ®Passenger ® Generator #Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned ` Q OTR O End-Use Q Container <br /> I Business Type (Fill all that apply) <br /> Q New Tire Dealer ® 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 /> I,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 ENFORGMENT'#T�►TIJ � <br /> V Pk - HAU ING AND M IPEST REQUIREMENTS Q:�I�I�It��4lrt <br /> O <br /> Q O 'PRC§42951 -Waste Tire Hauler Registration and Transport of Tires I Nntisp v11711on <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. +yorppli8rts Dsa�liTla <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> Q 014 CCR§18459 -Responsible Entities Complying with Manifesting Requirements ptp Ell <br /> 0 ; Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (14sfyflt�d11� 5?r ` <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 00.0 <br /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> O O 114 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> III ice'fj <br /> Q I Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ✓// <br /> itrtst� ✓ i,/✓ <br /> Other: § I <br /> Comments �►0.1 p t� ���;`r{,� vV`+n�.6�wv� 11 . Lit �.� � �.t ,.� <br /> Inspection Form IntZu <br /> Comments In > � - 57 v W tgnature Phone Number Alns �Ligniature ane NumberINSTRUCTIONS ON BACKgt` i `;li�aa►rnt�: ;. N) t s2os1 <br /> ■ White Copy:CIWMB Yeilow Copy:Operator Pink Copy:LEA ® ■ <br />