Laserfiche WebLink
Waste Tire SuAy & Inspection Reportlgnspection_Re_portNumber ■ <br /> State of California <br /> awnCIWM6Management <br /> (New Survey Form - Page 1 i 9 - 1 0 1 3 � <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Inspection Details <br /> TPID- _ Inspection Type (Fill one) <br /> T-7/Site Suffix: ' V 1 7 �1 I 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local j 1 If Referral,choose referral type(Fill one) <br /> Identifier. 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> f <br /> Physical Address M1 �] L= ri r JF( d4 <br /> _j <br /> Street <br /> Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title O AM (6 0 AM <br /> LJ__ 1 _ PM _._ —, --L O PM <br /> — I ----� 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/PTEA _F71 <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> � 0 Closed 0 Altered <br /> GPS Latitude � . 0 Hauler 0 Indoor <br /> 0 Inactive 0 Truck <br /> Longitude – I 0 End Use 0 Container <br /> ,J 0 Planned 0 OTR <br /> Business Type (Fill aft that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto E r Imb Rubber <br /> 0 Service Station 0 Hauler f er <br /> Part B - Y <br /> Inspection of Was X C Yak \ Facility ENFORCEMENT STATUS <br /> , HAULING AND MAN <br /> O v_ /ice 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste 7 <br /> 0 0 PRC§42953-Contract CQe �� �Q Compliance Deadline <br /> 0 0 PRC§42956-Registra ` a <br /> 0 0 14 CCR§18459 -Resl � (�� l �}1^N Date IE / m / IE <br /> 0 0 14 CCR§18459.1 (a)(k � � � N_ <br /> 0 (Required for NOV of EXT) <br /> 0 14 CCR§ 18459.2.1 -S <br /> 0 0 14 CCR§18459.3-Ret <br /> 0 0 14 CCR§ 18460.2-Mar 0-�`\ rs 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§ 18461 -Manift V \k b <br /> 14 CCR§ 18462- <br /> 0 0 Manife erators <br /> 0 In Compliance - No Violations <br /> 0 0 Other: § - - <br /> Comments <br /> 7 l <br /> 1 1:' T[ I t., %.�t1✓oj#:, "?/(4 () (.1!C, <br /> - <br /> < Ove i/J ( 't�Yv `jt`f r l ' i� i /i'td r i i 1/�( Gr,1 f,i <'rr r r?')(7�+ f J n L.' - TP 3 j <br /> -- - <br /> I �.1 _� -G" �`tf ' -� � ' -f ,-r f ( tit < VP� 'i C/C/, <br /> Inspection Form Included: 0', <br /> Comments Included: <br /> 0'Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />