Laserfiche WebLink
«r , Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California Survey Form - Page 1 1 8 - 01 4 8 2 3 <br /> CtWMB 181 New 04/04) <br /> Californla Integrated Waste Management Board <br /> Part A--Survey_ -_ -_ _ -- BLUE OR BLACK INK-PEN ,_ <br /> Business Profile Inspection Details <br /> TPID- l Inspection Type (Fill one) <br /> Site Suffix: `—� 0 5 40 Routine ® Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - <br /> Inspected By Inspector <br /> Physical Address <br /> p� Inspection Date ` J <br /> Time In Ti lme Out <br /> Business Rep Title 0 AM O AM <br /> O PM - O PM <br /> — <br /> i Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (rill all that apply) (Fill all that apply) (Fill all that apply) <br /> Y ® Active Passenger ®Generator 0 Outdoor <br /> O Q Closed Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> 0 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 <br /> Part B Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility <br /> ,�/ ,�t (E_.. }gyp <br /> PRC§42951 ' Y1 �i11�3r <br /> -Waste Tire Hauler Registration and Transport of Tires <br /> PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> O Q PRC§42956-Regis trationlDecal in Vehicle <br /> O ® 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q O /. / <br /> 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB �.°,�i/ <G'%%, ✓= / <br /> Q Q <br /> 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days ✓rte //r i:/`i ir?�yii"%'� <br /> 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> / <br /> QQOther. § <br /> Comments ���,•� � (�,r,,Vvi� •• ��� � rtir�'� �I l/"� _l� �y ��- - <br /> Inspection Form Included: Q• <br /> Comments Included: QI <br /> usirfess Rep s ig reNumber Ins ll Sig t Phone Number <br /> r?;sy&g - - 62081 <br /> INSTRUCTIONS ON BACKE'X AM P LFT <br /> While Copy:CIWMB Yellow Copy Operator Pink Copy:LEA <br />