Laserfiche WebLink
�i Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California Survey Form - Page 1 I 0 2 r' 7 <br /> CIWM1 <br /> B 181(New 04104) r <br /> California Integrated Waste Management Board <br /> Part A-Survey- _ _BLUE OR BLACK INK PEN <br /> Business Profile - _ Inspection Details <br /> 7PID- 4t Inspection Type (Fill one) <br /> Site Suffix; e Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: O CHP Q CIWMB Q Complaint Educational Visit O Other <br /> Business or Facility Name <br /> inspected By Inspector <br /> ✓��` <br /> Ph <br /> ' LAddress CAAeAA�V�f�� ( j 0 <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM Q PM <br /> -- -- - -- - Operational Status FrIme Type I Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> v <br /> t t ® Active Q Passenger le Generator O Outdoor <br /> C 0 Closed Q Altered <br /> GPS Latitude O Hauler Q Indoor <br /> O O Inactive •Truck <br /> Longitude _ O Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) _ <br /> O New Tire Dealer 0 Auto Repair S Trucking Fleet 0 Government Q Retreader Q Dismantler 0 Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body 0 Car Dealer 0 Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> I <br /> Part B -Inspection of Waste Tire Dealer, Generator, Hauler and End Use Faclty <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 7'/..•Ui /��/fit%�l'�/��/�/,� ./� <br /> 0 Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q 0 PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q ire Program ID <br /> Number from C1Wh48 �`r� "!/'• //, i�- <br /> O Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Lags within 90 days ��� /.,=� , <br /> Q 0 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q O 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 14C R§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 O Other: § <br /> Comments <br /> I fI�GIL� ti��—Gor-,2�3-�tt✓�C_ t'�._l' _� _�__"i��_�`!���t— cc.�i +�"2�va.�-. <br /> f <br /> �InspectionForrn Included: 2�'�/S^/�.$ 97j 7,68 <br /> Comments Included: Q - — -- -Phone Numb - nature <br /> nape - — - <br /> sin ss R s ignature er Phone Number J <br /> 62081 <br /> INSTRUCTIONS O BAC , ." z .,;,� '?/ ;'.� ' JMi P L I 3 <br /> hila Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> i <br />