Laserfiche WebLink
Waste Tire Survey & Inspection Report inspection Report Number ■ <br /> State odCalifornia <br /> Survey Form - Page 1 1 1 0 1 3 5 5 7 <br /> CIWMB 181(New 04104) <br /> California Integrated WastesteManagement Board <br /> Part A-Survey _ BLUE_OR BLACK INK PEN <br /> Business Profile Inspection.Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: <br /> O QRe-ins <br /> Re-inspection QReferral <br /> Q Observation® Routine <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier:_ Q CHP Q CIWMB QCom Complaint <br /> Q Educational Visit Q Other( <br /> Business or Facility Name <br /> Inspected By Inspector <br /> C 3 q - r %amu <br /> Physical Address 0 <br /> Inspection /— <br /> Date D g / o g <br /> Time in Time Out <br /> Business Rep Title O AM O AM <br /> I , <br /> O PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) Q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> t I®Active Q Passenger ®Generator Q Outdoof <br /> O Q Closed Q Altered do <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> �usiness 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 ®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 1 Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements ;�:; sp• <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 z <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 <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities " r, <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ^ - 3•;. - <br /> Q Q Other: § Baa <br /> Comments kwl t6y lGli(ITWtZVW ISS AO'te : <br /> a ' <br /> pfdQ5 IMrAtt rtiJGS'it "hY.tS Am S 1+0 or s•f 3 re_ <br /> r nmo zyt C2S -AA4ye—Q_0 -s TPU-* remaiilis ac five for <br /> ,Cr mf ` Bnajihan ✓Ic;.>a On A% e <br /> Inspection Form Included:O ` U 4 <br /> Comments ncluded: — �4 <br /> 06 <br /> Business Reps <br /> Signature _ Phone Number s ctoes S ature Phone Number <br /> 1,�e`Q,;�•4r�` �,�.� �.( ,ar;� -- 62081 <br /> ■ INSTRUCTIONS ON BACK 1" F •' ,4( rA All P ; . 1 3 <br /> 5 ® ■ <br /> White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> 0626304.0266 <br />