Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report Number <br /> stWMB1at.of allternia Survey Form - Page 1 - Q $ Q <br /> CIWMB 181(New 04/04) <br /> California Into9ratod Waste Management Board <br /> Part A-Surve/ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- �� _ D / Inspection Type (Fill one) <br /> Site Suffix: / Routine Re-inspection® Q P Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 1/47 A Q CHP Q.CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Nam <br /> j Inspected By Inspector <br /> Physical Address <br /> vw^✓1#I-,'—C� v^7' ��� Inspection Date / ./ 0 <br /> --- <br /> Time In Time Out <br /> Business Rep Title 'Z� O AM Q AM <br /> r 2 / U e PM Q PM <br /> f/ln Operational Status Tire Type Business Role Storage Type <br /> Tire Count( I h /PTE) } (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r (/� (Y Active Q Passenger ®Generator dD Outdoor <br /> O Q Closed Q Altered <br /> �►PS Latitude Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude _ Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ®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 Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility y <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. fF <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 w ' <br /> Q Q <br /> 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years. <br /> Q Q ' <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers w`. <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 <br /> Q 1 Q 1Other: § - <br /> comments I <br /> hero <br /> 1 , <br /> Inspection Form Included:Q -71 <br /> �y <br /> Comments Included:Q — Pone <br /> _ <br /> IB sin s Rep's ure PtYone Number I es Signature Phone Number <br /> INSTRUCTIONS ON BAC s " R IE1 62081 <br /> }� /kp <br /> . 0716504.0045 Ihite copy civ Yellow Cory:operatcr Pink Copy.LEA ® ■ <br />