Laserfiche WebLink
■ Waste Tire Survey & Inspection Report Inspection Report NumberSuto ■ <br /> cFWM 1131(NCalifornia Survey Form - Page 1 1 6 . 1 4 1 3 7 8 1 <br /> CIWMB 181(New 04/04) <br /> CalHomia Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details — <br /> TPID- I © _ ' Inspection Type (Fill one) <br /> Site Suffix: `3 I*Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �� If Referral,choose referral type(Fill one) <br /> Identifier 0 CHP 0 CIWMB 0 Complaint0 Educational Visit 0 Other <br /> Business or Facility Name <br /> 6 <br /> :�, n /e�s Inspectee�d By Inspector <br /> Physical Address `{`�/ I Y 3 vl ' 0 I I��iLcc <br /> Tra C l'1 , ^-5Sf� Inspection Date (� - / '3 I <br /> l q Il/�41- Title <br /> ( Time In lJ Time Out \l•l <br /> Business Rep U/} Title _ Q AM Q AM <br /> RM k b-L 1C,- Ow�— O PM O PM <br /> ��— Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) O (Fill one only) (Fill ail that apply) (Fill all that apply) (Fill all that apply) <br /> b 0 Active 0 Passenger S Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude - 0 Hauler 0 Indoor <br /> O 0 Inactive •Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder Other �t�Q <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> u <br /> r a ' ' :' W, M <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires y sous. <br /> �� Fay '. <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. , <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 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 /> 0 0 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 /> 0 O re Ss^ <br /> 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 1 0 1 Other: § <br /> Comments ` (N -fqs 40t • 110a1 _ WO.S "fed .' <br /> hew ,ter, &qNtS5 1'-S YVLOS-Ni r <br /> r v•. 1"§; rrnwi �.S fo ra-" r <br /> TL 84$I 1 S <br /> Inspection Form Included:0 .;A <br /> �a <br /> Comments Included:0 Business Rep's Signature Phone Number I or' gnature Phone Number <br /> INSTRUCTIONS ON BACK IEIXIAIMIPILIEI JIF213 62081 <br /> ■ ® ■ <br /> White Copy CIWM116 YelloCopy O erator Pink Copy LEA <br /> F7r.1_;r,4J4. ©3rJ C�-I� 39b- `fS�o <br />