Laserfiche WebLink
r� Waste Tire Survey & Inspection Report Inspection Report Number <br /> state CIWIVI f 81(Now <br /> Survey Form - Page 1 i 1 - 1 4 1 4 7 9 1 <br /> CIW Mf3181(New 04104) <br /> California Integrated Waete Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile i'Inspection Details <br /> TPID- ] Q _ h Inspection Type (Fill one) <br /> Site Suffix: 1 / f / / , Routine Q Re-inspection Q Referral Q Observation <br /> Local !�� If Referral,choose referral type(Fill one) <br /> Identifier. Gei, j VA1jL.1 f", Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name j/ �+�� r <br /> IInspected By Inspector <br /> r.tiQ 1'- <br /> Ph ai Add�a <br /> l a 5'U D i&j,.,S S-f <br /> � Inspection Date � y � o 3 <br /> Gam _ /',/, gSys <br /> 4 'f Time In Time Out <br /> Business Rep Title O AM Q AM <br /> rO PM O PM Operational Status Tire Type Business Role I Storage Type <br /> Tire Count(Whole/PTE) O (Fill one only) (Fill all that apply) (Fill al(that apply) (Fill all that apply) <br /> ' ' G 4F Active Q Passenger Q Generator * Outdoor <br /> O Q Closed f 40 Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O O Inactive Q Truck <br /> Longitude - End-Use Q Container <br /> O Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> iQ Used Tire Dealer Q Auto Body Q Car Dealer O Collection Q Crumb Rubber <br /> Q Service Station Q Hauler ®Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility 10ENFQRCEMENT 3TA7U3_ __......_ <br /> V} A HAULING=AND MANIFEST REQUIREMENTS <br /> OTO PRC§42951 -Waste Tire Hauler Registration and Transport of Tires .O Notice Of Violation Q Extension <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers, CQM Iance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle I <br /> O O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements :pate Ilam ' m <br /> O 1 - <br /> O 14 CCR§ 184591 (a)(b)(c)-Tire Program ID Number from CIWMB w <br /> I i I <br /> O 1 O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Regulred for NOV or EXE <br /> O O 114 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years JI <br /> 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers t (^� f /CMS EntofC •Rt <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities I _ <br /> y <br /> O I O + 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators % "•v'.t. ..., ' <br /> 11 <br /> 00Other: § <br /> ---�.. ....-- <br /> Comments <br /> Inspection Form Included: i ^ <br /> Comments Included: _ — L7�� 73S <br /> OI,Business Rep's Signature Phgns Number I o s Signatu Phone Number <br /> -- — - - - <br /> INSTRUCTIONS ON BACK GICtxr�] J � )( a.hlf p — I 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />