Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection ReportNumber ■ <br /> Slate of California Survey Form Page 1 15 1 Q 31 4 <br /> CIWMB 181(New 04104) <br /> California Integrated Waste Management Board <br /> Part A-Survey__- BLUE OR BLACK INK PEN <br /> Business Profile Inspeodon Details <br /> TPID- / 3 7 - Inspection Type(Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection 0 Referral O Observation <br /> Local / - If Referral,choose referral type(Fill one) <br /> Identifier �i� yt�,i� �U� Q CHP Q CIWMB Q Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name /61� Inspected By Inspector <br /> ,71�7�4./ti a `l / G' i -L- �t <br /> Physical Address <br /> Inspection Date C, <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> f/ O PM O PM <br /> r - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) / <' (Fill one only) (Fill all that apply) (Fill all that apply) (Fig all that apply) <br /> r ° 9 Active 0 Passenger i Generator Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude 0 Hauler i ®Indoor <br /> 0 O Inactive 0 Truck <br /> Longitude - O Planned 0 OTR O End-Use O Container <br /> Business Type (Fill all that apply) ---- -- — - <br /> 0 New Tire Dealer Q Auto Repair 0 Trucking Fleet Q Government 0 Retreader Q Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer Q Auto Body 10 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 /> 11:`0 <br /> � t <br /> O` 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires 0 kotloeOfokatiofr 0Eatsrrafot ' <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. Comptianee Deadline- <br /> 0 <br /> eadlinei0 O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements _ s <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB �' .. <br /> -' <br /> O O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 yearsz <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> O 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 <br /> 0 O Other: § <br /> Comments `fes--J � <br /> ,,tom ,%,bP�-r5�► _ <br /> Inspection Form Included: <br /> Comments Included: r <br /> Buss s Rep s gnature Phone Number Inspectors Signature Phone Number <br /> INSTRUCTIONS ON BAC i ICjX AjA4 P E 1 3 62081 <br /> ■ White Copy.CIWMB Yellow Copy.Operator Pink Copy:LEA ® . <br /> 0703R04.0496 <br />