Laserfiche WebLink
Ct Waste Tire Survey & Inspection Report Inspection Report Number <br /> 11 State of California <br /> CB181e04/04) <br /> California Integrated Waste Management BoardSurvey Form - Page 1 - 0 6 A <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details . <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: <br /> Q Routine Q Re-inspection ® Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: f <br /> S' ��j`�c�.-U— Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name v <br /> r Inspected By Inspector <br /> Physical Address <br /> Inspection Date <br /> Com- <br /> Time In Time Out <br /> Business Rep Title Q AM <br /> DD O � 0 AM <br /> t,-QY � � - D -_ � � � @) PM iJ d'C l 5 ® PM <br /> Operational Status 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 ® Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude — Q Planned ® OTR Q End-Use ®7 Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 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 OiO N ; <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 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 <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 /> Q Q . 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q 1 Q 1 Other: § nny-vt�� <br /> Comments S t& 5�1 UVI evw�t���c.�.� M15, <br /> C2 A. �— PO r-cu rpt.-s 5 i+-t_ 'i►�. <br /> i�tn S \1 t S e S (��� - �•c t> IA 78 L 5 f t —1 I 57 ZI P <br /> ff L t <br /> Inspection Form Included: Q. <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number 41nlector.s g ature Phone Number <br /> INSTRUCTIONS ON BACK orrect lncorre" ,+� P E ! l 62081 <br /> " 3Y , <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA 1 ' <br />