Laserfiche WebLink
09259040552 <br /> Waste Tire Survey & Inspection Report. Inspection Report Number <br /> State e}Cainemia I 1 - 11412 2 5 <br /> Cgraled 1steManage Survey Form - Page 1 _j <br /> Callfemia Integrated Waste Management Board <br /> Part A_- Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- F=L <br /> � Inspection Type (Fill one) <br /> Site Suffix: b 0 Routine Q Re-inspection Q Referral. Q Observation <br /> Local F_ If Referral,choose referral type(Fill one) <br /> Identifier: I :�)Cxv-� ��l�l�V 1 r l ��/r t 1 V/ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> S __�~✓ t, <br /> Physical Adds st <br /> L��0 � L�9L6�,o-1410tmhlc <br /> Inspection Dater <br /> City State ZIP Code Time In Time Out _ <br /> Business Rep Title I l l ;r 1 7 AM Ir—II ,� L Q AM <br /> 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 /> i t ® Active Q Passenger Q Generator le Outdoor i <br /> - - ,- - ( ------- - ,---- - -p <br /> GPS Latitude 1 . I 1 Q Closed Q Altered <br /> t Q Hauler Q Indoor <br /> I <br /> —y—�---' -� Q Inactive Q Truck <br /> 10 I I I Q End-Use QContainerLongitude Q Planned OTR <br /> _ t <br /> Business Type (Fill all that apply) <br /> Q 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 t_I' r lrYICAJ <br /> Part B Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility tiENFORCEIlli* TA=T] <br /> Ot.& zv axe»a tarn3 ;.v ie Q } <br /> HAULING,ANDxMANIFEST'REQUIREMENT,S III 1,1� ��,�.1 �� <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of TiresNotice.Of V!olatlonExteosion <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance. dlinet K <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> (ReqdxNOVorFX7)Q Q14 CCR§ 18459.2.1 _Submittal of Comprehensive Trip Logs within 90 days <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 l CIWMB Enforcement <br /> Q Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> ® In,Compliance,_= No Violations <br /> Q Q Other: § <br /> Comments l <br /> -- -C(cxAJ 12c-- cel 2 <br /> Inspection Form Included: O -� ��o <br /> 6Comments Included: B aes Reps Signaturee!�Yir Insp ct s i ature Phone Number <br /> y.,i <br /> INSTRUCTIONS ON BACK Corr ct. Inddh*ctt',l ) AlENX Ap P L E Z 2 3 62081 <br /> Yellow <br /> "i <br /> White Copy. WM Yelbw Copy:Operator Pink Copy:LEA , <br />