Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California )t �/�j �/�y {Q} (/J <br /> cIWMB181(New 04104) Survey Form - Page 1 i V W `+ V <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: 3 2 C Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> i Identifier: Q CHP Q CIWMB O Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Ph sical Address <br /> Inspection Date <br /> 07 / <br /> 7 ' '5;- I Q <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> 0 P 0 P <br /> Operational Status The Type 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 /> � � � � a � D C� <br /> Active Passenger ® Generator ® Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR O 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 gam,; a <br /> Q Service Station Q Hauler Agriculture Q Shredder Q Other <br /> p '_. . Facility ENPORd,010«NTSfi�S $ <br /> Part B - Ins Inspection of Waste Tire Dealer, Generator Hauler and End-Use m <br /> YV AO HAOLING AND MA FEST REQUIREMENTS O Q Nc#IAe<q{ �ltaJatl4i>E <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires , <br /> 010 PRC§42953-Contracts with Registered Waste Tire Haulers. COrttpltan � Rdfl�js <br /> O Q PRC§42956-Registration/Decal in Vehicle ' <br /> Q O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Rata <br /> Q Q 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 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 O 14 CCR§18460.2 Manifest System Requirements for Registered Waste Tire Haulers Q JTZ' /;/ <br /> 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Mlru <br /> O O 14 CCR 18462-Manifest S stem Requirements for Tire Dealers or Waste Tire Generators <br /> O ® § Y 9 O J►7�� Ja'P11, 9i/ �� ✓% <br /> Q Q Other: § - i-- yf f- %/ %/ l✓�i. f/% ' <br /> Comments I C'iGl U ct S i l� k <br /> 47"y e-.5 « , t4l,1 t 5 5 ci r-e_ <br /> C."f 4�, <br /> 4-L7u� (�7� l <br /> 'Inspection Form :nc <br /> ncluded: Q <br /> Comments luded: Q; — S _ �:� - �FJ -�L.7C� <br /> Business Rep Slgnatu a Ph - <br /> al'1�Number n or's Signature Phone Number <br /> INSTRUCTIONS ON BACK C a `. �tt4f 'I�G'tr - _ 3 62081 <br /> _ �_ ° <br /> ■ White Cop CIWM Yellow Copy:Operator Pink Copy:LEA ® S <br />