Laserfiche WebLink
Inspection Report Number <br /> Waste Tire Sutey & Inspection Repor.state <br /> C1WM 181(NowCaliforniSurvey Form Page 1 f 8 - 10 2 5 8 86 <br /> CIWMB 48!IMew OMD4) � <br /> California Integrated waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details f <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: w ® Routine Q Re-inspection Q Referral Q Observation <br /> Local �1 If Referral,choose referral type(Fill one) <br /> Identifier: �17ageA,,iti C0L'r"+X Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other j <br /> Business or Facility Name (I V inspected By Inspector <br /> L K a L)�,s ma4 ler I <br /> Physical Address S q – t oZ— <br /> �b�1 Nab fir, <br /> Inspection Date `'{ ! Q / O T <br /> Co- q 52-ob <br /> Time In Time Out <br /> Business Repqq__ Title O AM O AM <br /> ti Y S iT1A VYL tt O PM O PM <br /> S} 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)j <br /> �J ® Active ® Passenger ® Generator Q Outdoor <br /> D Q Closed Q Altered <br /> GPS Latitude Q Hauler Q indoor <br /> Q inactive Q Truck <br /> Longitude – i Q Planned Q OTR O End-Use ! Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader ® 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 INFORCAMMTJ9TAIl J <br /> Q O` PRC§42951 -Waste Tire Hauler Registration and Transport of Tires tdfi�l+ l 17f YiOUtlan Q U><tenaltn <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. �>� n - <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements / <br /> 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O .(14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days 'r• SjlNC�{Lar1 <br /> -y r-•��s-�G etr F+a �' <br /> Q ® 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers _ <br /> 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O �_ <br /> O OSystem <br /> 14 CCR 18462-Manifest Re Requirements for Tire Dealers or Waste Tire Generators <br /> § q <br /> OO Other: <br /> Comments 06-tu:►n Tt,�2b, kvr \(Taste gDaect `N T�Ct I�VI A vl i�P5� <br /> WA,StC +jCe haw ling . A+ preSeof YZry fehl Nkst-e - iw; are, howled , PoLowt <br /> Re�dcti CA 6-I<o ��� �;s'►1art1'lctl^�), (,cst11� mctl4es+ sJsem already, <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> Bu ness Rep's Signature Phone Number n pector Ignature Phone Number <br /> IN �;�° 62081 <br /> ,INSTRUCTIONS ON BACK 'a_ AtMiL� i 3 <br /> Whits Copy:C1WM8 Yellow Copy:Operator Pink Copy:LEA <br />