Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of 181CaliforniaNSurvey Form - Page 1 i 1 - G G 6 6 G o <br /> CNVMB 181(New 04/04) <br /> California Integrated Waste Management Board <br /> Part A-Surve BLUE OR.BLACK INK PEN <br /> Business Profile. Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 3 a 8 - 0 ' <br /> ®Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ( If Referral,choose referral type(Fill one) <br /> Identifier: •+fan c V,4h O CHP 0 CIWMB O Complaint .Q Educational Visit O Other <br /> Business or Faeility.Name U Inspected By inspector <br /> /til,2s4 Coctsf Cbrie-ref� P <br /> Physical Address 3 + ' O I �jA4- Rist.(Z <br /> L. <br /> Inspection Date C C) <br /> Time In Time Out <br /> Business Rep Title ®AM ! ®AM <br /> I O O PM I ( Q O PM <br /> r intcao Waf-bvis 41, — <br /> Operational Status Tire Type Business Role Storage Type <br /> ckvAck S '. <br /> Tire Count(Whole/PTE) 0 . (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r r (P Active O Passenger ®Generator O Outdoor <br /> O Q Closed O Altered N11A <br /> GPS Latitude �Hauler Q Indoor <br /> O Inactive ®Truck <br /> Longitude - End-Use Container <br /> - Q Planned 0 OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer O Auto Repair If 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 0 Crumb Rubber <br /> Q Service Station 0 Hauler Q Agriculture Q Shredder ®Other C�iVIPv�- 1✓' fir/� <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility !.-,EN Fbk6WMIENt STATUS <br /> e Of Violation (� xtensron';, <br /> Q PRC§42951 Waste Tire Hauler Registration and Transport of Tires <br /> r <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. ,Comptfa,Ce <br /> O O PRC§42956-Registration/Decal in Vehicle ;w, <br /> M, <br /> 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q .Q 14 CCR§18459.2.1-Submittal of Manifest Forms.and The Trip Logs within 90 days 1,?„<,+ t i���r �Woo <br /> ��h,� <br /> 0 O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers ':( Refen,td f ClWMk#y�E �° a, <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> R <br /> o O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators` <br /> Other. § <br /> Comments <br /> MINI <br /> Iliy►a ' Kg o <br /> Fate.l i+y 15 u 5 YK4 trot i5h2rd *Ye katA&j e.r 7DS for a.6f -#Frc Ur Vi c.es, inyd ic{,S <br /> Q n r v-f s 17 c uc+ . No Ares stored b%, <br /> ` ` ` ,tDS r r laces 3 -3 tura s- o V% la 1. <br /> scc�s re P� <br /> Inspection Form Included:Q <br /> Comments Included:Q - / f + (2M)�S2S r' <br /> Buslness Rep' Signature Phone Number Ins r's Skdature hL Phone Number'. <br /> INSTRUCTIONS ON BACK: ?' �} ISIS A'h P LjEj 1112131 62081 <br /> ■ White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA © . <br /> 0524204.0779 <br />