Laserfiche WebLink
08184p40�53 <br /> « , Waste Tire Survey &.Inspection Report Inspection Report Number <br /> �r CIWM f181(N- Survey Form - Page 1 19 _ 10 7 9 2 9 7 <br /> clwMe tee(Na.Dual - <br /> calitomla Irdagmtad Wast.Manage t Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- •� Q (� I Inspection Type(Fill one) <br /> Site suffix: �� 3 9 I I 7 I / .Routine Q Re-inspection Q Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S,^) 740.q g,�,��'�,� �vn/ _ Q CHP Q CIWMB 0 Complaint 0 Educational Visit Q Other <br /> Business or Facility Name (1 Inspected By Inspector <br /> I �raW fl — ST�/li(.SS �� I / - To <br /> Physical Address L—_Mx(_µ�� J <br /> �y221 <br /> Street G, NlA�-c_Pa — _j <br /> N g521S Inspection Date LOL&I FTI O Q S <br /> rtC y State Z!P COce J Time In Time Out <br /> Business Rep Title <br /> ,/ e 0 AM O AM <br /> /�1 G r2Nt/OS� �rr'Ge �✓`�C ��O PM LL-1: Q PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) {n( (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active Q Passenger 10 Generator . 0 Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Hauler 0Indoor <br /> —.0 <br /> Q Inactive 0 Truck <br /> Longitude ; Q End-Use Q Container <br /> j I Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer 0 Auto Repair O Trucking Fleet Q Government tQ Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body O Car Dealer O Collection tQ Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture 0 Shredder Other L; (DAw <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT ST�TL�WMaR =IPQIR6M <br /> E <br /> Notice Of Violation Extension <br /> o rQ PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O 0 PRC§42953-Contracts with Registered Waste Tire Haulers. 1.1op <br /> liance Dread <br /> O 0 PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements m / mO Q 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> O Q 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Requior EXT) <br /> O 014 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> I <br /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred IC-IWMB Enforcement <br /> O 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O 014 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •I om liance - No Violations <br /> O Q Other: §, <br /> Comments <br /> tiles �- <br /> -l - e Imo—i�Q(Q. i' ,5 <br /> Inspection Form Included:Q <br /> I Comments Included:Qdusinss <br /> 4�8 gld�3_ <br /> j ep's ' nature Phone Number Inspectors signature Phone Number <br /> INSTRUCTIONS ON BACK •orre Incorrect: IMIPILIEI 1112131 62081 <br /> ■ Wrote C py:C 8/ Yellow Copy:Operator Pink Copy LEA ® ■ <br />