Laserfiche WebLink
07312040470 <br /> Waste Tire Survey & Inspection .Report Inspection Report Number ■ <br /> °' S�teofCa1"e`el' Survey Form - Page 1 1 8 - 1 0 7 3 5 3 0 <br /> CnYM6 tai(New 04!04) <br /> ealifomia Integrated Waata Managamant Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I 7 0 4/ 3 Y d ®Routine Q Re-inspection Q Referral Q Observation <br /> Local ^ If Referral,choose referral type(Fill one) <br /> Identifier: -� � /e„,-�,.,_ - Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 Inspected By Inspector <br /> L �xu•Q..—�.rnnc ►�, —1 c..,^S+v�-rte <br /> Physical Address _a 9 FlToN <br /> � � g � J <br /> Street G <br /> Inspection Date <br /> I S 8-v c.�+-trn GPt _ 9S•ZI r I <br /> City Slate ZIP Code Time In Time Out <br /> Business Rep Title m OA O AM <br /> t ' ®PM LLJ 6 PM <br /> t__U rq; )S 11J_,,>eA.Q--.--_I I 1�1NCn1_cry ro•�r� <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 <br /> r i D 40 Active Q Passenger 0 Generator Q Outdoor <br /> e f Q Closed Q Altered <br /> GPS Latitude L i Q Hauler ®Indoor <br /> f (( l 1.. _[_j <br /> __ -I O Q Inactive ®Truck <br /> Longitude - I �—1 I I I -1-� Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) 1 <br /> Q New Tire Dealer Q Auto Repair ®Trucking Fleet Q Government Q Relreader 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 Q Other i <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STgTUS <br /> V A HAULINGAND MANIFEST REQUIREMENTS 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 / m m <br /> Q Q 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXTJ <br /> Q O 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 t CIWMB Enforcement <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q © 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In C-!Ili mpliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> vtc.—�n�x ak+czv� or 1��S—�I a. �• X_ rtd- <br /> -�,, A_lx._Lar.�vi.on-EMTs a-r- <br /> Inspection Form Included:Q / <br /> Comments Included:Q V 7� <br /> Business Signature Phone Number pedor's Signature Phone Number <br /> INSTRUCTIONS ON BACKCorre t: ncorrect: EXAMPLE1112131 62081 <br /> ■ Whit Copy CIW Yellow Copy Operator Pink Copy.LFA ® ■ <br />