Laserfiche WebLink
=Fa; Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CIWMB 1 181(New O4/04) <br /> Stateor80Survey Form - Page 1 1 1 - 1 0 1 3 0 7 5 <br /> (New <br /> Cal%omla Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK_ INK PEN <br /> Business Profile Inspection Details <br /> TPID- 'r - u / Inspection Type (Fill one) <br /> Site Suffix: G� f 4D Routine Q Re-inspection Q Referral Q Observation <br /> Local - If Referral,choose referral type(Fill one) <br /> Identifier: � ��� � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name inspected By Inspector <br /> Physical dd ss T c 39 - ( 1) 1 7tn,w_ ?ttk-c' <br /> II(-is w. <br /> s�v C CA C?5,;2 ob <br /> Inspection Date I � I J I / G 4^ <br /> n <br /> Time In Time Out <br /> Business Rep , j Title A 0 AM 0 AM <br /> Car t t.U"lpL�,iJ - 0 PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(W hole/PTE) C) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active Q Passenger 0 Generator ®Outdoor <br /> GPS Latitude 0 Q Closed Q Altered <br /> Q Hauler Q Indoor <br /> o Q Inactive •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 ®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 Dj cam✓-1/I a <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. r <br /> Q O PRC§42956-Registration/Decal in Vehicle " <br /> O tO 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements ? <br /> O O 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 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 /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities a y <br /> O 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O 1 O Other: § <br /> Comments ��..1:,� ,, the Yt TWi.,s RdN � ►Y� II�W-1 V�.(AJ n0'+�(�: !�(,L S <br /> i� t�a�l`Lon 7'I'+'e -dor Al t- 6tiry;ce cyto(- *Z des go-1, CTASyitwed. Two <br /> 1 S to '(i o e- 44 aK-t : gL I q C04 13Y6 <br /> Inspection Form Included:Q..� 4(,�� � < <br /> I Comments Included:Q a,�'��—' Q <br /> L Business Rep's Signature Phone Number In o s SI a ra Phone Number <br /> INSTRUCTIONS ON BACK til 4tXIAIMIPILIEI. 1 1 2 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> C7(C1 jy 04.0322 <br />