Laserfiche WebLink
a= , Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CWMB 81(Nmla Survey Form - Page 1 14 - 3 6 9 <br /> CIWIYB 181 Waste <br /> M nage <br /> GIMu lnberarsd Wastuaneq�mrrrrtBoard BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- 3 2 O / Inspection Type (Fill one) <br /> Site Suffix: - 0 Routine Q Re-inspection 0 Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: St. �Q ,�, �- 7 O CHP Q CIWMB o Complaint o Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical AAess ,3 r �L�/S/ffl97Vi'�✓oR <br /> Inspection Date p ;2— / O S / D <br /> Time In Time Out <br /> Business Rep / Title�iyJ O AM O AM <br /> L 4S� /�/SIC''r c�GI' -- O PM O PM <br /> 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) r �� <br /> _ (a Active it Passenger 0 Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude O Hauler Q Indoor <br /> O 0 Inactive Q Truck <br /> BLongitude - O Planned Q OTR O End-Use Q Container <br /> ess Type (Fill all that apply) <br /> 0 New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> •Used Tire Dealer Q Auto Body O Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 O PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 O 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <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 years <br /> O O 114 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q O Other: § <br /> Comments <br /> -- —_.. <br /> Inspection Form Included:Q <br /> Comments Included:Q � <br /> Businesk1cepysignatbqPheumber Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK E X A SIA PJLJEJ 111213162081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0705904.0322 <br />