Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> U State of California J /� <br /> CIWMB 181(New 04104) Survey Form - Page 1 I - 1 0 0 n <br /> Call(ornla Integrated Waste Management Board <br /> 778 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection/ Inspection Type (Fill one) <br /> Site Suffix: l ®Routine Q Re-inspection Q Referral Q Observation <br /> Local r— If Referral,choose referral type(Fill one) <br /> Identifier: ( �p�_�j/�— 1 C Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name U , / Inspected By Inspector <br /> PhysicalAddress <br /> E� �0T�t l LLG <br /> a000 Vf, CSV ��� �t1��. - <br /> h �,tr � Inspection Date <br /> S <br /> Time In Time Out <br /> Business Rep Title �/ rA / i O AM O AM <br /> Ga" Qllls VIC2 /`it t� 1 V ®PM D f ® PM <br /> — Operational Status Tire 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 /> 1 � <br /> Active @ Passenger 0 Generator Q Outdoor <br /> N d <br /> GPS Latitude 0 Q Closed Q Altered Q Hauler Q Indoor �T <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned ®OTR Q End-Use Q container r <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 0 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <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 CIWMB - . <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days u - <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q .Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers s t <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities ` <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q 10 1 Other: § <br /> Comments RoyfAe M In „-}7 <br /> yr� v <br /> T:�A 1 is F'e I od utp <br /> rm .hr <br /> a", Oak on Si i� or aen�ated ov► 91 , J3rr�n n Ti r� �yi�s Navy(. <br /> t" 4 <br /> jo <br /> Inspection Form Included:Q 7-M � <br /> Comments Included:Q Busine Reps 1anature Phone Number In ctoes S ature Phone Number <br /> INSTRUCTIONS ON BACK E X t P t12 9 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br /> 4_1 6 00 4 04.4_14_1 2— <br />