Laserfiche WebLink
■ 08129040640 <br /> Waste.Tire Survey & Inspection Report Inspection Report Number . <br /> CrWMl181(Now Survey Form - Page 1 1 5 - 10 7 3 4 2 9 <br /> CIWMB 781(Now 04104)' Y <br /> Cal117 Intprat.d Watts Manegemmt Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> itIIoType (Fill <br /> Site Suffix: J % n <br /> Q Referral Q Observation <br /> Local I/,� If Referral,choose referral type(Fill one) <br /> Identifier: L V 0 CHP Q CIWMB Q Complaint p Educational Visit 0 Other <br /> Business or Facility Name UInspected By Inspector <br /> GR - ZoE] L� - Faso <br /> Physical Address <br /> lo�,2`f Aftg t Ave, <br /> Sheet n <br /> q5�t� Inspection Date <br /> 6t_ <br /> I Time In Time Out C� <br /> _y State ZIP Code <br /> Business'Rep TitleJ. O AM O AM <br /> O PM 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 appy) <br /> r ®Active O Passenger ®Generator Q Outdoor r <br /> i D Q Closed 0Altered 'W` <br /> GPS Latitude . ( O Hauler Q Indoor <br /> L---J, O Inactive ®Truck <br /> Longitude I ' ( I I I O Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer O Auto Repair t®Trucking Fleet Q Government O Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture Q Shredder . tQ Other t I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A 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 /> O 0 PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m <br /> O 0 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Requl ed Ior NOV or <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIW M8 Enforcement <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities _ <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> ®In Compliance - No Violations <br /> 0 Q 1 Other. § Jam,, J /� <br /> Comments ,.f11e,�,� n .1/_ .� p �K. �le_w_�—q rrW � <br /> ryi ��eks�S ✓ljelwfe 7 jo ale ,- previus ✓ib11 -us . Na liras <br /> 17'DreA On OVke�s A'0 VID(�t9rtS kXO_ kd <br /> Inspection Form Included:0 p9 p/ <br /> Comments Included:Q /-P=` �"'^r"""— 239 e1fy�Y —`�-9 <br /> Business Rep's Signature Phone Number Inspect s Signature Phone Number <br /> INSTRUCTIONS ON BACK E X A Aq P L E 62081 1 '2 3 <br /> ■ While Copy.CIWMB Yellow Copy:Operator Pink Copy.LFA ® ■ <br />