Laserfiche WebLink
Waste Tire Survey & Inspection Re ortInspection Report Number <br /> State of California /I {� <br /> cIWMB181(Now 04104) Survey Form - Page 1 . 10 4 V <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Buslness Profile I Inspection Details <br /> TPID- { Inspection Type (Fill one) , <br /> Site Suffix: 1 ' 4Z -7 / Routine 40 Re-inspection of al Q10 'servation <br /> Local /� -�—+ If Referral,choose referral type(Fill one) <br /> Identifier: �- �,r per} � ll Q CHP Q CIWMB Q Complaint 0 Educational Visit Q Other <br /> Business or Facility`Name r' j <br /> Inspected By Inspector <br /> �Physical dress � f � � � <br /> LInspection Date <br /> Time In Time Out <br /> Business Rep Title 0AM O AM <br /> 0 PM 0 PM <br /> LGf 1Li1J v�hf�h <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) a (Fill one only) (Fill all that apply) (Fill all that apply) . (Fill all that apply) <br /> 0Active Q Passenger ®Generator ® Outdoor <br /> O O Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 indoor <br /> O 0 Inactive * Truck <br /> Longitude - 0 Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer Q Auto Repair 0 Trucking Fleet 0 Government 0 Retreader Q Dismantler 0 Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body 0 Car Dealer Q Collection O Crumb Rubber <br /> Q Service Station Q Hauler 0 Agriculture 0 Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility ENFaiEMBIT STATUS_ <br /> Y i4 M/#UlIN4ANR M11►M[ @$'f_tEtU1Ftla <br /> Mt*N' 5 <br /> O O Q N6tlr,.eVf.Vlolatlo� O 6xt�ttslon <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Gprnpliahce DOedllne <br /> O 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting RequirementsEil <br /> 0 0 14 CCR§18459,1 (a)(b)(c)-Tire Program ID Number from CI\NMB I <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (RegUlred:far NOV or IX7] <br /> 0 0 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers IT TIlf[#� j�NM� t Edforcar[ t <br /> f <br /> 0 0 _ - T <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities -- - <br /> O 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators F <br /> �fll�tf413o <br /> _O 1Ae <br /> o i f r <br /> O Other: § �;� ...<�:...; �� 4 ­ 1 <br /> Comments ; — t49 / 7-776(6 69,1 -- - <br /> �.,, !aY- 1S' G�__ `��^r r'N3 ,) �vx $r�-t�,C-� <br /> rVD V/D �a <br /> Inspection Form Included: 0 <br /> Comments Included: Q - -- o 's Sia ure <br /> B ness R Signature Phone Number ect r ig Phone Number <br /> i !gipv _ <br /> INS <br /> TRUCTIONS Ott #r .,,. i'!� > � tE— 62oa1 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />