Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report Number . <br /> CIWMBte 181(M.CalftrnlSurvey Form - Page 1 1 8 . 1 0 0 8 0 6 5 <br /> l:MlMB 187(Naw 04104) <br /> California Integrated Waste Management Board <br /> Sart A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> I TPID- � /, c7 �J � � / � � � Inspection Type (Fill one) <br /> Site Suffix: 7 /� (� �'/ ®Routine Q Re-inspection Q Referral Q Observation <br /> LocalSG If Referral,choose referral type(Fill one) <br /> Identifier: � ` Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Na e <br /> J fdr..s <br /> ((�]y{/i�; Inspected By Ins ectorPhysical O T /��'' <br /> /6777 -- - I <br /> 11 JfzT0 A ����Q Inspection Date /' ,5 / 0 7 <br /> ,`t{�•`_ �T Time In Time Out <br /> Business Rep L Title �/ / *AM O AM <br /> dr'!1 �L ( 1111111'PM O PM <br /> - — Operational Status The Type Business Role Storage Type <br /> Tire COU ho /PTE) 10 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> t t ®Active Q Passenger ®Generator ®Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude - Q Planned ®OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q 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 ®Other s �� <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 014 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q ® 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § <br /> Comments <br /> Inspection <br /> _lam-s�-�-_{ z - ,�� - ---- � ► Y--r.—_ (p/l�t�L_,l - Y zrr - <br /> ---_�^.rt�•+�v�A�� +moi r�. fV'fL�_- 4 <br /> V - 0 <br /> inspection Foran Included:Q - <br /> Comments Included:Q ' _ <br /> Busih essFlip's Signature Phone humber nspector's Signature Phone Number <br /> ■ <br /> ��W Ai INSTRUCTIONS ON BACK ' I I�1 IE V� I 9MI P I{,I E1 1112131 62081� ■ <br /> White Copy:CIWMB Yellow Copy.Operator Pink Copy.LEA <br /> 0708104.0052 <br />