Laserfiche WebLink
■ Waste Tire Survey &Inspection Report Inspection Report Number E.694. <br /> Stats of Callfomla <br /> CIWMB 181(New 04104) Survey Form - Page 1 1 9 - 10 0 6 1 7 5 <br /> caftfornia Integrated Waste Management Board - <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 O -7 O Q t Inspection Type(Fill one) <br /> } Site Suffix: ` 7 ®Routine Q Re-inspection Q Referral Q Observation <br /> Local L If Referral,choose referral type(Fill one) <br /> Identifier: per,,_(�€� ff p_ 0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other ' <br /> Business or Facility Name <br /> —./T^ � Inspected By Inspector <br /> I I L � �'c7�r I C� ed / <br /> Physical Address 3 ` _ J 0 <br /> // nn Inspection Date Q / (4- <br /> Time In Time Out <br /> Business Rep TitleO AM <br /> ^� AM <br /> vl�a►'"�C-5 K r �GF�( � 3 O � ®PM � 3 3 O PM <br /> Operational Status Tire Type Business Role- Storage-Type. <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed O Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O (a inactive 0 Truck <br /> Longitude - Q Planned 0 OTR 0 End-Use Q.Container <br /> Business Type (Fill-all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet 0 Government O Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer O 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,HaulerandEnd-Use Facility <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. $ <br /> O O PRC§42956-Registration/Decal in Vehicle , <br /> O Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements ; E. <br /> O O <br /> 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> 14 CCR§18459.2.1-Submittal of Manifest Farms and Tire Trip Logs within 90 days <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O <br /> 14 CCR§16460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators .,. <br /> Q .O Other: § ? <br /> Comments <br /> r• _ <br /> �^ -'f6 a s Entered <br /> Inspection Form Included:Q <br /> Comments Included:Q - - -�� �- <br /> Business Rep's Signature Phone Number In tor:s.Signature: . :Phone Number, <br /> INSTRUCTIONS ON BACK • p E X( Aja P L i � 62081 <br /> ■ <br /> Whit - ©e Copy.CIWMB Yellow Copy:Operator <br /> Pink Copy.LEA ■ <br />