Laserfiche WebLink
t== Waste Tire Su ay & Inspection Report* Inspection Report Number <br /> Stale of California <br /> CIWMB 181(New 04104) Survey Form - Page 1 t $ - 1 0 2 5 6 1 4 <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK.PE_N_ <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 1 - Routine Q Re-inspection Q Referral Q Observation <br /> Local l^ If Referral,choose referral type(Fill one) <br /> Identifier: CL�r �_I Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name T Inspected By Inspector <br /> Ph sisal Address 7�j" <br /> Inspection Date © [�. / ! / <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> P (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> f Active Q Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 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 FacilityENFORCEMI:I r 9:: h , <br /> _y HIQkl141NG AND MANIFEST REQUIREMENTS <br /> 10 Notltsti-of Vfolatlon (� ftil�ii <br /> QQ PRC§42951 -Waste Tire Hauler Registration and Transport of Tires x i <br /> i <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Co <br /> R]pfFence ROsdllne <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 Responsible Entities Complying with Manifesting RequirementsDote m I i <br /> Q 1 Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB f <br /> 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 daysQQu � Y � j�"��: <br /> Q O %. , <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years J S,y/may <br /> Q Q 114 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Ifaaf tf i tY4!ME � �1, <br /> Q Q 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 ;_ I3CIZir <br /> Q Q Other: § <br /> Comments ©hCe� <br /> (O ►�-s <br /> t�Aj -�?y.�5 K I r4r—s L')a5"Tc, <br /> Inspection Form Included: ����� <br /> Comments Included: - l.v <br /> usiness Rep'4 gnature Phone Number nsp or s ignat Pone Number <br /> - i 62081 <br /> INSTRUCTIONS ON BACK Corte 1n�olRect E ) A M P I E t 12 <br /> yQ White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> Q <br />