Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of <br /> CIWM Survey Form Page 1 I fi - 1 0 4 7 3 0 <br /> CIWMB 181(New <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPiD- Inspection Type (Fill one) <br /> Site Suffix: l 3 $ l © outine A Re-inspection Q Referral Q Observation <br /> Local w I If Referral,choose referral type(Fill one) <br /> Identifier: SI,,,, J�a y�t Z-. R�, J Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name r ((y Inspected By Inspector <br /> jcal Address <br /> Inspection Date ' I -2-3 <br /> 2 ? I G c+ <br /> Time In Time Out <br /> Business Rep Title Q AM 0 AM <br /> O PM 0 PM <br /> Ar-r-e, 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 t@ Passenger #Generator ®Outdoor <br /> 0 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 O Container <br /> Business Type (Fill all that apply) <br /> 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 SINN N r, <br /> V<<'A: HA4LINQ-AN0-MA`IFE&T REGUIREMONTS I r <br /> Q O Q fNatilcet�►#a}itlt�n ? <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> PRC§42953-Contracts with Registered Waste Tire Haulers. yes yr i r� z'r <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Delta / <br /> 0 <br /> 14 CCR 18459,1 (a)(b)(e)-Tire Program ID Number from Cf WM$ <br /> O i O i 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O <br /> 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 /> , <br /> i ;,.� <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators s >/% <br /> 00 Other: <br /> Comments f.cel;&5 (40,0, $r/3 D/0 �+ M16 t rTe— <br /> Rres 6c,"P <br /> Inspection Form Included: Q J� <br /> Comments Included: Q - -✓ ' - <br /> 60', <br /> Business Rep's Signature Phone Number Insp ores g ure Phone Number <br /> INSTRUCTIONS ON BACK Go(Ft3t� I'OCt; I 62081 <br /> _ - � E P I <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />