Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report NumberState of ■ <br /> cFwMB 161(Ne Survey Form - Page 1 1 9-- 1 0 1 3 6 4 4 <br /> CONMB 181(New 04104) <br /> califomla Integrated waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: / y 3 8 y 9 O / 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalJ/ _ If Referral,choose referral type(Fill one) <br /> Identifier: f"" 1'40 /+ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Businesss or Facility Name Inspected By Insp <br /> neec r <br /> Physical Address uBQO%ILjKv✓A <br /> - <br /> �'�e,�n Inspection Date <br /> (off Time In Time Out O <br /> Business Rep Title 0 AM AM <br /> J <br /> / .2— QPM � 9 / I O PM <br /> y/fie Operational Status Tire Type Business Role Storage Type <br /> Tire Count(W hole/PTE) IV, (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> GPS Latitude O 0 Closed 0 Altered 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 10 , 0 Other: § <br /> Comments F�-°u � �/ � C G!/`YTc >i i✓�f �cf <br /> /itui,G+-thy Ley Q-LC c�%t IUBrr � �°!� �^ /`/.6�✓, C� u•�/� <br /> Inspection Form Included:0 <br /> Comments Included:0 BWRs__ ture Phone Number Inspector's Signature Phone Number a <br /> INSTRUCTIONS ON BACKE X a tN4 P L E 1112131 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0622104.0024 <br />