Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> •iir_ <br /> rr StatMB 81(New Survey Form - Page 1 7 - Q �J 7 <br /> CM7LB 181(Naw r4age <br /> California IntegratedWaale Management aoard <br /> .Part A-Survey. BLUE K INK PEN <br /> Business Profile Inspection Details — 063470 v tt <br /> 9W O0 <br /> TPID- f� Inspection Type (Fill one) <br /> Site Suffix: 1 3 7�f 15] v L , ®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 /> L�rute� Rem Pss-f,�► c-5_� 3 q _ Ft FoT11 <br /> Physical jAddress <br /> Street <br /> c�'j�} l(lrnT Inspection Date V <br /> �,--`--ter" � '7�4�e L� Time In Time Out <br /> Business Rep Title JJO PM O PM <br /> `J Operational Status Tire Type Business Role Storage Type <br /> i (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) ;O <br /> ®Active ®Passenger ®Generator Q Outdoor <br /> O Q Closed Q Altered <br /> PS Latitude Q Hauler Q Indoor <br /> G <br /> —�-__-'O Q Inactive ®Truck <br /> Longitude - ! Q Planned ®OTR Q 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 1 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ®Other L�7NF <br /> yry�Q �oia— <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility CEMENT STATUS____V A HAULING AND MANIFEST REQUIREMENTS ce Of Violation Q Extension <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <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 (Requ red for NOV or EXT) <br /> Q O 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 Q Referred 1 CIWMB Enforcement <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q ® 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> .0 , 0 Other: § <br /> Comments ub� �yw�,Ctl�yr ,L(. —( -�. ! -rU I�u�u_q �l s �D I bn fy <br /> lYI�ICr �tilYJi"`e�a1_I 1 <br /> &Y—)i _✓ems <br /> A ILr <br /> Inspe on Form Included:Q W� <br /> Comments Included:Q �`�=� <br /> Business Rep's Signature Phone Number Ajln*r's i ature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: (( P 1. E 1 2 3 62081 <br /> ■ White Copy.CIWMB Yellow Copy Operator Pink Copy LEA <br />