Laserfiche WebLink
fCi6 <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Stateof <br /> 81(Nrnla Survey Form - Page 1 12 - 0 3 2 0 <br /> CIW M8191(New 04/04) <br /> California Integrated Waste Management Board <br /> Part A-Survey <br /> BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / � � � � Inspection Type (Fill one) <br /> Site Suffix: ® 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 O Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> .S'u ri i3ssivr/�.ryv.� <br /> /4z C-?A - <br /> Inspection Date do S p a3 / 7 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> 0 PM 0 PM <br /> d' � f"7 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 /> •Active Q Passenger •Generator ® Outdoor <br /> O O Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude — Q Planned Q OTR Q End-Use ® Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® 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 , ,4 <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 O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> ^ _ y <br /> Q I; ) 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years ft <br /> 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q O 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 t <br /> 1010 1 Other: § <br /> Comments Zt.Q /r ,� <br /> 4"_6A, UJX7/ W71 marcs 94 <br /> ,Inspection Form Included:Q <br /> Comments Included: Q <br /> B siness s Sign re Phon umber Inspector's Signature Phone-Number <br /> INSTRUCTIONS ON BAC �, p l 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />