Laserfiche WebLink
- , Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State orC1(Ne a Survey Form - Page 1 1 5 -- 1 0 1 3 1 7 8 <br /> CIWMB 181(New nage) <br /> CNHomla In Waste Managerrrnt Board <br /> Part A-Survey BLUE OR BLACK INK_ PEN_ <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix' 7 ®Routine Q Re-inspection 0 Referral Q Observation <br /> Local /9_ If Referral,choose referral type(Fill one) <br /> Identifier' �va ,:, Q CHP Q CIWMB Q Complaint 0 Educational Visit Q Other <br /> Business or Facility Name <br /> r Inspected By Inspector <br /> lie <br /> Physical Address <br /> �7G lti <br /> �� rs3s 4 <br /> Inspection Date J/ / L1 c U 7 <br /> Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> 1—�•�' �d.://-yctfZ ��L1���� — O PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r 0 Active Passenger 0 Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude _ Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer Q Auto Repair Q Trucking Fleet 0 Government 7 Retmader Q Dismantler 0 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 /> ,I <br /> Q 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-RegistrationlDecai in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days - <br /> Q 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 /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q (Other: § <br /> Comments ��� /?,�J��,L�,ld,t Zl�r j' r!'Cs.y c�aY� y��. •�il�s7tdr!`�' ..a/� <xvytt��/: <br /> ���C�/ 1/,fir � �,%�,�y� �, r:euz.-� G�'� ;L,,•.�� - GT-t �J <br /> Inspection Form Included:00 <br /> Comments Included: <br /> &II <br /> nese Rep's SignaturePhone Number Inspector s Signature Phone Number <br /> ■ INSTRUCTIONS ON BACK �����li I EJXIA MI P IL I E1 1112131 62081 <br /> White Copy CIWMB Yellow Copy Operator Pink Copy.LEA I <br /> 0710204.0211 ' <br /> 1 <br />