Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report Number ■ <br />State of California Survey Form - Page 1 1 7 -1 01 3 1 l <br />CIWMB 181 (New nage <br />California Integrated Waste Management Board <br />'art A - Survey BLUE OR BLACK INK PEN <br />Business Profile . Inspection Details <br />TPID - <br />Site Suffix: / 3 g ,g 1 O oZJ - 0Local <br />/ <br />Identifier: Sall p/ <br />Business or Facility Name v <br />Physical Address (� <br />0?.3 y5" &avj r <br />Inspection Type (Fill one) <br />0 Routine Q Re-inspectlon Q Referral Q Observation <br />H Referral, choose referral type (Fill one) <br />Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br />Inspected By Inspector <br />39 - l o/ s1/'4 <br />Inspection Date 0 o2- / D d / O i <br />Time In Time Out / <br />Business Rep ,/�� Title Q AM Q AM <br />/� <br />gra.4 {�x`.-�"' /i X4rtll�C.l O PM O PM <br />Tire Count (Whole/PTE) <br />r t <br />GPS Latitude <br />Longitude - <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader 9 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 <br />Q <br />Operational Status <br />(Fill one only) <br />Tire Type <br />(Fill all that apply) <br />Business Role <br />(Fill all that apply) <br />Storage Type <br />(Fill all that apply) <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 Active <br />0 Passenger <br />0 Generator <br />Q Outdoor <br />O <br />Q Closed <br />Q Altered <br />Q <br />14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />Q <br />O <br />14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />Q Hauler <br />f' Indoor <br />0 <br />Q Inactive <br />Q Truck <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q <br />O <br />Q Planned <br />Q OTR <br />Q End -Use <br />Q Container <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader 9 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 <br />Q <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />O <br />O <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q <br />Q <br />14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />Q <br />O <br />14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />Q <br />O <br />14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years <br />Q <br />O <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q <br />O <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 <br />iQ <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />Q <br />1 Q <br />1 Other: § <br />,,)� � <br />TuE <br />Comments %tL y^ yu+J #�r 41-tWor <br />�'a�.`'�:-►� it a,�� d.! 1�� �� . �� �/� Bsto� �o �uf�� <br />nspection Form Included: <br />Comments Included: <br />INSTRUCTIONS ON BACK'. <br />White Copy. CIWMB <br />0705904.0327 <br />Phone Number Inspector's Signature Phone Number <br />E X A M P L E 62081 <br />Yellow Copy. Operator Pink Copy: LEA ® ■ <br />