Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report Number <br /> Slate C1WM of 81(Now Survey Form Page 1 1 3 - 10 2 5 7 09 <br /> CIWMB 181(Naw 04(04) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Ptnflle - - (Inspection Details - <br /> TPID { D r� - r Inspection Type (Fill one) <br /> Site Suffix: l O( ` 4D Routine Q Re-inspection 0 Referral Q Observation <br /> Local L If Referral,choose referral type(Fill one) <br /> Identifier: M � � � � Q CHP Q CIWMB 0 Complaint Q Educational Visit Q Other <br /> Business or Facllity Name ` inspected By Inspector <br /> Physical ddress 1 ��� <br /> cA Inspection Date D <br /> I /7 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM O PM <br /> r Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) D (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f &Active + Passenger 9 Generator 0 Outdoor <br /> O I Q Closed Q Altered <br /> GPS Latitude I Q Hauler Q indoor <br /> O Q Inactive IS Truck <br /> Longitude - Q Planned O OTR O End-Use Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer 0 Auto Repair Q Trucking Fleet 0 Government O Retreader Q Dismantler O Tire Derived Fuel <br /> 0 Used Tire Dealer Q Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station Q Hauler O Agriculture O Shredder 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility <br /> O 0. i � Rtlolatn - �n <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires ! yi" <br /> Q PRC§42953-Contracts with Registered Waste Tire Haulers. tl <br /> Al. r <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O .14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements <br /> 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 /> O O 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 /> 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators l _ <br /> O O Other: § <br /> Comments <br /> /rcpt (A) fix-,e— ay 1, Puh rs 1 ►n� wi <br /> VA,v \ <br /> re�Cs w+�8 `�1�e ►�a�n1er�, �t wa ��t -�^et� o� <br /> 40 <br /> Inspection Form Included: Q <br /> Comments Included: - — — - - - <br /> Business Rep's Signature Phone Number a ure Phone Number <br /> W <br /> 62081 <br /> INSTRUCTIONS ON BACK A ;ddi P L E t 2 -A <br /> White Copy.ClWMB Yellow Copy:Operator Pink Copy:LEA <br />