Laserfiche WebLink
08052040235 <br /> €,- Waste Tire Survey & Inspection Report Inspection Report Number <br /> State ofCalilomla Survey Form - Page 1 1 8 - 1 0 7 9 4 4 5 <br /> CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- O � Inspection Type (FID one) <br /> Site Suffix: �j $ O�7O� ®Routine <br /> Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: c� -�� y;n ��Jr+1- Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> I Address <br /> ato j_t�z Sc wt <br /> CR- <br /> Physical <br /> a I 3 _ <br /> Physical Address j � � f�L!� <br /> I y l O S—L1—� orz`olo I vr_�CH t <br /> Street <br /> � Inspection Date <br /> City S_ �� �A StaieSL�P CCode I Time In Time Out <br /> Business Rep Title <br /> -- -- — <br /> Pm ®PMmW® M <br /> Operational <br /> Status Tire Type Business Role: Storage Type <br /> I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply). <br /> Tire Count(Whole/PTE): i <br /> r i r Q Active Q Passenger Q Generator Q Outdoor <br /> f <br /> GPS Latitude - ®Closed Q Altered <br /> Q Hauler Q Indoor <br /> T_-- I- _I,I I—_.1 '--1 O Q Inactive Q Truck <br /> Longitude - 1 i oEnd-Use 0Container <br /> I ,` _ Q Planned Q OTR <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 p Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder p Other I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> ---- - -- —...._._ <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 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 (Required for NOV or DCT) <br /> Q O <br /> 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/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 Q In Compliance - No Violations <br /> 010 1 Other. §, <br /> Comments "' <br /> S-:r.M Ct�ca^r�P—t.t.L_Fn�i Li.-.(�./—t �+.SiG� �d j-f r-T V - <br /> _C>11 <br /> Inspection Form Included:Q <br /> S/6$ 0 <br /> Comments Included:Q <br /> � �23 <br /> Business Rep's Signature Phone Number Inspector_Gfs Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Corre_CRW I1EjXjAjMjP[LjEj 1112131 <br /> . While Copy.CIWMB Yellow Copy:Operator Pink Copy.LEA <br /> t <br />