Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State B1811(Newif Survey Form - Page 1 i 3 - 1 0 0 6 7 7 4 <br /> CIWMB 181(New 04/04) <br /> califomla Integrated Waste Management Board <br /> Part A.Surve _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- j /� - Inspection Type (Fill one) <br /> Site Suffix: V a 3 9 b ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: .� t'/�l 11. Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name n Inspected By Inspector <br /> TY-(tCK WD r+S �y �^ <br /> Physical Address V . teA*,, 'RL4i Z' <br /> �(0 S'a p5 Rd-t - <br /> .S�ock-Im Inspection Date j � / a r'f � b <br /> Time In Time Out <br /> Business Rep TTiitle�, O AO AM <br /> O M <br /> r ��� �►VC� til�� -- � I 3 5 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ol C (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' J 0 Active 0 Passenger 0 Generator ®Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 4W 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 des � .f <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ®Other Pa_V✓YrTruck A tCL([�t�`f�iesAepaLr <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility s <br /> Q Qom,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 /> F." <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days �. <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 <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities �> <br /> Q OF <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ^;�• <br /> Q Q Other. § <br /> Comments RadkthS loll 4P.ZS dOq is ( r J-6 L/ � A A,0 Le of o ; /Sed <br /> ,} 1 8 �r s waste �&o_s "4 . <br /> Mani Arts viewed a4 noted� be •Ftld o+ rp&r!v- Dscussect -Kra v ►2-., <br /> andywy codrot br wa iia l�.�ia�s <br /> Inspection Form Included:Q <br /> Comments Included:Q •�� �7"' <br /> Slgnatur-e Phone Number 1K*ectoeJAIgnature Phone Number <br /> INSTRUCTIONS ON BACK P 11 <br /> 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA ® ■ <br />