Laserfiche WebLink
L�= Waste Tire Survey & Inspection Report Inspection Report NumberStato ■ <br /> CIWMBf 181(Nrnla Survey Form - Page 1 1 1 - 1006558 <br /> CIWMB 181(New 04/04) <br /> Califomla Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile - Inspection Details <br /> TPID- Inspection Inspection Type (Fill one) <br /> Site Suffix: 7 - / 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �CJit p/ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> � rl Inspected By Inspector <br /> Physical Address 3 - 0 <br /> / Inspection Date r0 <br /> G-oe�Cc�-r-•( G� 9�,3 7 <br /> Time In Time Out <br /> Business Rep Title 0 AML0 AM <br /> / a : 577 0 P I t7 6 Q M <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)I (Fill all dig apply) <br /> t r 0 Active Q Passenger 0 Generator •Outdoor <br /> O Q Closed ®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 /> Business 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 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Other <br /> L L � • <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENi=(YttalfAfi�tf�1TUS � - '" <br /> Y` A HA(Jt ING ANP MANIFEST REQUIREMENTS - -- <br /> Q Q I PRC§42951-Waste Tire Hauler Registration and Transport of Tires C)Notice Of Violation Extens;on <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Gaenpiiance Deadline-,_, <br /> Q Q PRC§42956-Registration/Decal in Vehicle —_ <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIW MB k <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q Q14 CCR§18459.3-Retention of Manifest Forms and Tire Tri Logs for 3 earsPENN <br /> . <br /> Q Q14CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilitiesk <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § <br /> Comments <br /> —a` <br /> &W W �%/ 60 4-e .09,7e Aoc 3 s <br /> Inspection Form Included:QI <br /> Comments Included:Q <br /> Bust SR s Signature one Number Inspector's Signature. Phone Number <br /> - F� � <br /> ■ INSTRUCTIONS ON BACK N4 X A P L E I- 62081 Z <br /> While Copy:CPNMB Yellow Copy.Operator Pink Copy:LEA <br /> 0628404.0074 <br />