Laserfiche WebLink
���31�44444 <br /> �I Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> 700_ <br /> 7r,t C.'Mg M f California I 1 1088040 <br /> California In'. ^ted WasteBManaO ment Board Survey Form - Page 1 <br /> Part A-Survey <br /> BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I I Q. Q l - © l Inspection Type (Fill one) <br /> Site Suffix: l Q 1 J I ®Routine �Re-inspection QReferral <br /> Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: slit, J('��(��n CO� 1� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name L V InspectedB <br /> I C�ktfl Frc�Sh l-t(1QS— I13 ;9 ly_ '� Insr�s� �, J <br /> Physical Address <br /> Sheer , 1 o 9 <br /> q!e Inspection Date <br /> 0 �� it <br /> State z �6� Time In Time Out( _ <br /> Business Rep/ pTitle,� '•< F r— i t0 AM Q AM <br /> J�C is .a000n IU,�1 WJ�O i --' o-= PM _.3 O O; 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 /> o O ®Active Q Passenger Generator ®Outdoor <br /> Latitude Q Closed Q Altered <br /> GPS Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> p Service Station Q Hauler Q Agriculture Q Shredder Q Other I —J <br /> Part B-Inspection of Waste Tire Dealer,Generator,.Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m <br /> O Q 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> 0 Q 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <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 I CIWMB Enforcement <br /> Q Q 14 CCR§18461'-Manifest System Requirements for Waste Tire End-Use Facilities <br /> I Q Q 14 CCR§18462'-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q 1 Q;1 Other: §`,� <br /> Comments �o <�� t.os� _oc�- -- r 1 'e.0. — QOS�`l w n �I-. <br /> ptl�eando-r_ux }e. <br /> (TIL 0. c�q��� 4wri CT <br /> Inspection Form Included:Q i <br /> Comments Included:Q — - !�1�✓��J (O �' ��—- <br /> B_st s ep's Signature_ Phone Number Inspecto*. ,.n.t—.r. Wj Phone Number <br /> ■ INSTRUCTIONS ON BACK Corr ct ncorrect: X)(�t) lE�IXIA MIPILIEI 111213 620811 <br /> White Copy: IWMB Yellow Copy:Operator Pink Copy.LEA ® ■ <br />