Laserfiche WebLink
F= Waste Tire Survey& Inspection Report InspectionReportNumber <br /> State CIWM ofCaliforniaSurvey Form Page 1 1 2 - 1 0 2 6 6 8 2 <br /> cMIMB 181(New 04/04) a - - <br /> calNor" Integrated Waste Management Board- <br /> PartA-.Surve BLUE OR BLACK INK-PEN <br /> Business Profile Inspection Details <br /> TPID- 13 3 2 5 .� � 0 / Inspection eTyType (R O O one) <br /> Site <br /> Site Suffix: RouutiO <br /> ne Re-inspection Referral� Observation <br /> Local . If Referral,choose referral type(Fill one) <br /> Identifier.. `�Da- u-G(�► ��/ (,� 1)CHP Q CIWMB . o Complaint 0 Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> S tDfk vi 1,13S 3 q _ �. D <br /> Physical Address l� Ttci <br /> ^, Inspection Date © / a d / D <br /> Frehch C&Y rip Cot95�3Time In Time Out <br /> _ Business Rep Title 0 AMa 0 AM <br /> JVt�/ 1 0 PM O p� L/ O PM <br /> Oct Plqrl <br /> Operational Status Tire Type Business Role Storage Type. <br /> Tire Count(WholelPTE) . (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)' <br /> r ®Active 0 Passenger `Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O O Inactive ®Truck <br /> Longitude — 0 Planned 0 OTR O End-Use •Container <br /> Business Type (Fin all that apply) _ <br /> Qrnment o-Retreader 0 Dismantler Tire Derived Fuel <br /> New Tire Dealer 0 Auto Repair a Trucking Fleet 0 Gove <br /> Q Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber C /I <br /> O service station, 0 Hauler O Agriculture 0 Shredder Other GI+t pjl l IYIQ L V <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility II CJ <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. y <br /> 0 <br /> PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O O 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB a <br /> 0 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days g €�. <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 3 <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O O Other: § G <br /> Comments b ;- TvtlS CtKd— `�( - TO Ito WIN43 . VAS )'LO e <br /> ` er ltai�l9mPmr7je ha ¢d /D s vm &41` o VLiqAY ad <br /> 'res oh j 414 ;A44s a mai&;-fs A rt cu, VJH& <br /> WAd. 1 iYePro (ram Ih'01ebk <br /> Inspection form Included o <br /> Comments Included: <br /> siness Rep's ature Phone Number Inspe is Si lure' Phone Number < <br /> t„ z 62081 <br /> INSTRUCTIONS ON BACKS 6: X Ak Fil Z 2 3' <br /> ■ White Copy:CIWMB `Yellow Copy Operator Pink Copy..LEA ■ <br /> 13529204,0025 <br />