Laserfiche WebLink
rj Waste Tire Survey & Inspection Report Inspection Report Number <br /> stat.01`8lilur Survey Form - Page 1 19 - 1 01 31 9 8 <br /> CIWMe,B,sU M nag. Y 9 <br /> Csleomis Intpntad Was"Management Board <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- _ O I Inspection Type (Fill one) <br /> She Suffix: 7 J9 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �QLCu� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 33 — <br /> J� Inspected By Inspector <br /> Physical Address <br /> - <br /> _S��.lu� inspection Data o , / o / / o -7 <br /> Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> 0 P QPM <br /> Operational Status Tire Type Business Role 9torege Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f ' i Q Active Q Passenger Q Generator Q Outdoor <br /> O •Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O li Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q 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-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 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 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 <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 Q Other: § <br /> Comments '_-,l y�� Ir( /Oo/ Ae/ 9e_- <br /> Y &< <br /> J�/'l f��•/'���'r O-�'� Ts.�.� .LES �+•. <br /> Inspection Form Included:Q �/�t ����,� �� ,• 7�� <br /> Comments Included:Q "V <br /> Business Rep's Signature Phone Number Inspectors Signature Phone Number <br /> -" <br /> ■ INSTRUCTIONS ON BACK � I)Y►X A P L E 1 ,2 I j] 62081® ■ <br /> 0716504.0030 White Copy,CIWMS Yellow Copy.Operator Pink Copy..LEA <br />