Laserfiche WebLink
08129040956 <br /> i., <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> 5" Survey Form - Page 1 1 3 - 1 0 7 2 8 5 8 <br /> CNVMB tel(New"GA) <br /> Call}°mia Integrated Waete Management IdoarO <br /> Part A-SU V BLUE OR.BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> 1:0M Site SufFlX: Routine Q Re-inspection Q Referral Q Observation <br /> Local �� SA�t.i11 / ( If Referral,choose referral type(Fill one) <br /> Identifier: (�6 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> n Inspected By Inspector <br /> L_/qlI JOt� YA <br /> Physical Add rss 3 f - ' <br /> ��1j55 /mac syi ar►� <br /> S7_ <br /> I — <br /> Street <br /> _ Inspection Date <br /> �ma/ <br /> � c. _C4 C7-5-205 <br /> city State ZIP Cod& Time In Time Out <br /> Business <br /> /Rep Tittllee 0 AM QAM <br /> t__SN_BL - /4{> T/----- -�i '" ✓--r -- -I lopm LLI :� O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> II� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) ; <br /> r r Q Active Q Passenger i Q Generator I Q Outdoor <br /> i0 Q Closed Q Altered <br /> GPS Latitude i I i I I Q Hauler Q Indoor <br /> �- •t----' Inactive Q Truck <br /> Longitude - I i Q Planned Q OTR Q End-Use Q Container <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 10 Other <br /> Part B-Inspection of Waste Tire Dealeri Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> -- - 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 Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / ID <br /> / 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 (Wed oired orNOV or <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 Referre I 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 .In Compliance - No Violations <br /> Q Q Other: § <br /> Comments /- <br /> �o �l�_ijvS.Ptr l or_ah Tlr rs d Zll_r s k ___ ' ,a 4_,°4/L�� <br /> N44n/G1FA C _ -- S'A fiJ le_WA5 � _Gy./saw W a <br /> kr_G_Er _5 <br /> ',e-4 A.vl- wAsr� <br /> —S� %2ctc�s A� Or.�n��Q—Q e2A7�d ILb ✓/01A7I''QVJ OC�Cv.J�E4t1S <br /> Inspection Form Included:Q 09 <br /> Comments Included:Q — •=r3 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK CKor o ct: 1EjXjAjMjP1L1E1 1112131 62081 <br /> ■ White Copy. IWMB Yellow Copy Operator Pink Copy LEA ® ■ <br />