Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> Board C IWMB 181(New 04104) Survey Form _ Page 1 1 2. 1 0 1 3 3 08 <br /> California Integrated Waste Management <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Detalls <br /> TPID- j Inspection Type (Fill one) <br /> Site Suffix: 1 g g - r Q Routine le Re-inspection Q Referral Q Observation <br /> Local F If Referral,choose referral type(Fill one) <br /> Identifier: f� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ✓ <br /> Inspected By Inspector <br /> P4:�cal Address <br /> s <br /> �J LA-11 �— <br /> Inspection Date Q y (o <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> 0 PM Q PM <br /> Operational Status li Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active Q Passenger ; ®Generator ®Outdoor <br /> � <br /> Latitude Q Closed Q Altered <br /> GPS O Q Hauler ®Indoor <br /> o Q Inactive ®Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ®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 Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility A <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 l <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 Forms 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 A'a eFd <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> a . <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q 1 Q 1 Other: § <br /> Comments me-Co, 47".4 DfG -4 - -m CASI';6405" 41 140-LYi3 <br /> Inspection Form Included:Q <br /> Comments Included:Q - - - <br /> Busine Rep's�f nature Phone Number I o—es Sig are Phone Number <br /> INSTRUCTIONS ON BACK �� AIM P L E g 62081 <br /> x `ter nen'��Fsyn'-.�"'ei1wT <br /> ■ White Copy CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br /> P71 f;17190 214.0` 5 <br />