Laserfiche WebLink
LSd <br /> Waste Tire Su ;y & Inspection Report Inspection Report Number <br /> State of California <br /> CIWMB 181(NewSurvey Form - Page 1 I 1 - 1140842 <br /> California Integrated Waste Management Board <br /> Part A- Survey _- BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ` y / • Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: '_ <br /> 62e 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name r J Inspected B <br /> l � � P Y Inspector <br /> Physical Addr <br /> � os- Inspection Date�, <br /> Time In Time Out <br /> Business Rep Title <br /> j� oAM ® AM <br /> j D I Q PM o Q 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 /> 0 Active ® Passenger 0 Generator 0 Outdoor <br /> O 0 Closed ® Altered <br /> GPS Latitude ® Hauler 0 Indoor <br /> O 0 Inactive ® Truck <br /> Longitude - 0 Planned ® OTR ® End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet ® Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station ® Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility NEEQ�>> � � <br /> V A ; HAULINd ANb;,MANIFEST. ,R,�,VjItEMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires ri <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 0 l PRC§42956-Registration/Decal in Vehicle <br /> 0 i 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements t . <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> 0 0 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers i <br /> 0 0 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 0 Other: § <br /> Comments <br /> Inspection Form Included: 0 <br /> Comments Included: <br /> Business Rep's Slgn ture Phone Num Inspector's Signat a hone Number <br /> - e - <br /> INSTRUCTIONS ON BACK �Correct; Incorrect' A'° p I ( I 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Co y: ! <br />