Laserfiche WebLink
=6 , Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California Survey Form - Page 1 1 2 - 1 0 1 0 6 1 9 <br /> CWMB 181(Naw 04104) <br /> Gllfomla Ntepreted Waste Management Boartl <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ,A ' - O ' Inspection Type (Fill one) <br /> Site SufFlx: lP ®Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identlfier. jo allh Q CHP Q CIWMB Q Complaint p Educational Visit Q Other <br /> Business or Facility Name <br /> aL I T.Q1, & `/i Le S Inspected BY Inspector <br /> f <br /> Physical Address <br /> god >c. R64 2d, <br /> r "� ll/AWP JJCA �y5 ` Inspection Date / —1 � / 17 <br /> IL—,ve 7 r Time In Time Out <br /> Business Rep Title O AM O AM <br /> 0P 0P <br /> 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 /> r r ®Active Q 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 Q End-Use Q Container <br /> Buslness 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 , •-e Q <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ®Other U� CUvtfrac�UV <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility Yl 1 <br /> -7 <br /> O O 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 s <br /> O O 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 <br /> O ® 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 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 1010 1 Other: § <br /> Comments R insae_ d _ 1t S J_ e iry umdt q WQS /LD'{-ad IACS J <br /> h <br /> rrn5 Ar - <br /> Inspection Form Included: O G v� <br /> Comments Included: Na� "r +S192/r""�� LAAqqB MRep`s S gna re Phone Number: -Insp 's Phone Number <br /> ■ INSTRUCTIONS ON BACK I FE X A P e 51E� 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0708104.0098 <br />