Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report NumberState ■ <br /> Stat (Now fCelSurvey Form - Page 1 1 9 . 1 0 0 6 $ 9 <br /> CIWMB 181(New 04!04) <br /> Callfamla Integrated Waste Management Board <br /> PartA-Survey BLUE OR BLACK_ INK PEN <br /> Business Profile Inspection Details <br /> TPID- _ © Inspection Type (Fill one) <br /> Suffix:Sux: 'a Routine Q 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 /> Sh e td a �^ <br /> Physical Address <br /> 515 for-' R00A #tel vCl�� <br /> Sia„( _fon /1 t A n� n Inspection Date O q <br /> � % 4 t/ Time In Time Out <br /> Business Rep Title O AM Q AM <br /> 0 PM 0 PM <br /> ba{i bC1 Q� Q r Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) e)) (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> r I ®Active ®Passenger ®Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> I <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 l�Cle g � <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 Forrns 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 Q 14 CCR§16461-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 1 Q 1 Other: § <br /> Comments <br /> �J0 arli eSts ka.� 0 n sine. a C i l - aAj-eS e s <br /> j& M6r'e_ .esks on si-fe Area S-i oUs <br /> Inspection Form Included:Q, I <br /> Comments Included: <br /> Business Rep's Signature Phone Number In or's 19tur <br /> a Phone Number <br /> ■ INSTRUCTIONS ON BACK JEWAIMIPIDET 1 2 3 62081 <br /> 0716504.0014 White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA ® ■ <br />