Laserfiche WebLink
' •' 08129050066 <br /> «e1, Waste Tire Survey & Inspection Report Inspection Report Number . <br /> crwM81'm°n'° Survey Form - Page 1 17 - 1 0 7 2 8 0 4 <br /> CIWMB 181(New..9 <br /> Calilomla Inepnhd Wnb Management Board. <br /> Part A-SurveyBLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID191 q Q 10E <br /> Inspection Type(Fill one) <br /> Site suffix: O O BRoutineQ Reins eclion <br /> p Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. San TOCl9Ui n c, uu -y Q CHP Q CIWMB Q Complaint. Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> I Litt -Tr t-1Gk Sew I_ce_s_r tnc• 1 3 q I O I <br /> Physical Address - i �,f 15�1oY1 LLAGRS-1 <br /> - <br /> Street <br /> I Inspection Date <br /> I Trac GA 953?7�i <br /> City i tate ode ! Time In Time Out <br /> Business Rep Title <br /> ' <br /> O AM Q AM <br /> O PM O PM <br /> Cng.: ---Q dmo:Ski L_P_resiCle„__f__� <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> Active Passenger 40 Generator 0 Outdoor <br /> I I Q Closed Q Altered <br /> GPS Latitude _J• Q Hauler Q Indoor <br /> I 0 Q Inactive Q Truck <br /> Longitude — r I I__J Q Planned 0 OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) -- <br /> p 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 Other IG2 <br /> t_{oC_kl�_5�`/ �Kepair�5ci <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS' Q Notice Of Violation Q Extension <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q QPRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Dst°m / m/ m <br /> Q Q 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Requbed for NOV or EX') <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <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 0 In Compliance°- No Violations <br /> Q 10 1Other. § <br /> Comments C�orly —}f16 AO'be it ::*L j k( 1 11 Aa; <br /> Ro�trttle� rtsuo_ <br /> _Ptvat_Yant 21O ..I uG�w r15 la�� Vf.�o�Ler4_�Sgc_ <br /> �Jd_nn -l4� sloe since 10 00 <br /> G , + EDT�rQraQ-�q hat ceras r �,�as eco <br /> Inspection Form Included:Q /�833 D o"V ` 3�I <br /> Comments Included: — <br /> Ine s Si ature Phone Number lnsp&a&s Signatu Phone Number <br /> 62081 <br /> ■ INSTRUCTIONS BACK Correct:* incorrect:X(l� AMP.L 1 2 3 ® ■ <br /> White Copy.CIWMB Yellow Copy:Operator Pink Copy.LFA <br />