Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> r State of California <br /> C IWgratedMB 181(New 04/04) Survey Form - Page 1 1 5 1 0 1 3 6 3 2 <br /> Callfom is InteWaste Management 13—dPartA-Survey _ _ BLUE OR BLACK INK PEN <br /> Business Profile -- Inspection Details_ <br /> TPID- Inspection Inspection Type (Fill one) J <br /> Site Suffix: - <br /> - 0 Routine Q Re-inspection Q Referral Q Observation <br /> Loam <br /> _ � If Referral,choose referral type(Fill one <br /> )IdentifS� 0CHP QCWMB QCom Complaint <br /> Q Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> p �� P� <br /> A�Uo �n /p &*7;9417 <br /> Physical Address o <br /> r� Inspection Date D 6 6 <br /> Time In Time Out <br /> Business Rep Title <br /> n 9 49 AM C� �AM <br /> O PM D O 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 /> ° <br /> 0 Active �Passen Passenger <br /> 0 Generator Q Outdoor <br /> O Q Closed Q Altered 41Z <br /> �+PS Latitude � Q Hauler Q Indoor <br /> O O Inactive 0 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 Q Trucking Fleet Q Govemment Q Retreader Q Dismantler Q Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> O Service Station Q Hauler Q Agriculture Q Shredder i Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires ; <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> ' P I <br /> Q Q PRC§42956-Registration/Decal in Vehicle a t <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q O 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 01 Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q 014 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> O Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other. § <br /> Comments rac,fie "-,4 STET wavA r4>-er f Si�4� f-uc��li <br /> X41 a,& 91,/'e Griar,[/ .Coke /e -4&e ea( `Q, 4&e <br /> �P 61-ire �4 a t 6vQy�e $�Yy dl+z .fccov4sd � <br /> Szlk / *ted 4,4,r..xu� t�rQca." madA40.0u tac�i <br /> Inspection Form Included:Q d. ��' ,�lr �/ <br /> Comments Included: f C �/7 .�/a-+� VKz OS <br /> Business ep's Signature tone Number Inspector's Signature - Phone Number <br /> ■ INSTRUCTIONS ON BACK EEEVaFMMjEjXjAjMjP L E 11_713] 62081 <br /> White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> F-1619404.0055 <br />