Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report Number <br /> Slate of West. oa <br /> California Survey Form - Page 1 1 6 1 01 3 2 0 4 <br /> c FWMB 181(New W04)4) <br /> Califomla Integrated Waete Management Brd <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- S -3 .� - / Inspection Type(Fill one) <br /> Site Suffix: I( Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Gk� 50 0.L,,�,,� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name J Inspected B <br /> • �_��� i P Y Inspector �J <br /> Ph slcal Address <br /> `7—A) Inspection Date O C <br /> S Time In Time Out <br /> Business Rep Title Q AM OAM <br /> k ,,i,CA. 0 Cl) @)PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> The Countho TE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � r <br /> O Active ®Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Indoor <br /> O Q Inactive it Q Truck <br /> Longitude - Q Planned Q OTR ®End-Use Q 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 /> 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 <br /> 0 Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q 0 PRC§42956-Registration/Decal in Vehicle <br /> O 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 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O 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 /> O 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q 1 0 1 Other: § <br /> Comments <br /> V\ kAAX If <br /> �S ' r <br /> _ t <br /> Inspection Form Included:Q <br /> Comments Included � <br /> Business Rep's Signature_ one Number ,n ors Signature. Pho a umber <br /> . INSTRUCTIONS ON BACK ' X FAFM P�L E 1,,2 3 62081 <br /> White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA ® ■ <br /> 070811714.l_1r154 <br />