Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report NumberStats ■ <br /> CIWMB <br /> f181(Nmla Survey Form - Page 1 1 1 - 1 0 1 3 4 1 4 <br /> Cgrte 181sNew nage <br /> 4104) <br /> Cal'rfomta Integrated Waste Management Board <br /> Part A Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I '5 O _ Q I Inspection Type (Fill one) <br /> Site Suffix: Q Routine Q Re-inspection Q Referral Q Observation <br /> Local V If Referral,choose referral type(Fill one) <br /> Identifier: { ll� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address � <br /> 313(v S 44wj CR - <br /> OS I <br /> �� CA '✓wJ Inspection Date <br /> Time In <br /> II I �j Time Out <br /> Business Rep Title •AM <br /> f n Q AMefwt <br /> 0 PM / A V 9 PM <br /> I Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) f 5 <br /> Active Q Passenger i �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 /> L <br /> Business Type (Fill all that apply) -- - - <br /> Q Retreader Q Dismantler Q Tire Derived FuelTrucking Fleet Q Government Auto Repair Nj <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 <br /> Q Q 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 /> 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 <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § <br /> Comments /its Y - .-me- D w4w kJ <br /> no_kZ <br /> 'lr` 125 fair rle <br /> 2fsery' <br /> MIFR---loar wok a+w{,°ah 4iim a li #Arm ao- e) (T Aeej <br /> Ui evv fi rl�lG�_dimes, Tie ai '3;& am <br /> �i ar , <br /> Inspection Form Included:Q <br /> Comments Included:QPusin .. <br /> - T r <br /> Rep' ignature Phone Number s ors S n ture Phone Number <br /> ■ INSTRUCTIONS ON BACK X p FL1 3 62081 <br /> White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0601904.0010 <br />