Laserfiche WebLink
08234040342 <br /> j Tire Survey & Inspection Report InspectionReport Number <br /> Slate a CalirorniaSurve Form - Pa e 1 I1 - 1088153 <br /> 12-Waste <br /> ?rate 181,Waste <br /> Management <br /> Caliromia Integrated Waste Management Board Y <br /> Part A-m " BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- n Inspection Type (Fill one) <br /> Site Suffix: ®Routine �Re-inspection �Referral <br /> Q Observation <br /> Local N If Referral,choose referral type(Fill one) <br /> Identifier: ��� SO o` r+ ( pts �St� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> ^'�- Inspected By Inspector <br /> Phy ical A9dress - fMot <br /> I` A A I HA"VJ <br /> —I L4 33 7-1 1 en Lam, s 'D2 <br /> Street <br /> pInspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title <br /> O AMO AM <br /> D&IJL_ O PM L__T• 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 /> r - *Active �Passenger �Generator <br /> •Outdoor <br /> io Q Closed Q Altered <br /> Latitude ' <br /> GPS � I I Q Hauler Q Indoor <br /> —. Q Inactive Q Truck <br /> Longitude - ) j^ I Q planned Q OTR Q End-Use Q Container <br /> i i•I _ �_ I <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Relreader 0 Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> i <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility E--NFQgC-MENT STATUS <br /> y q 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 <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 EX77 <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 In Compliance - No Violations <br /> Q 1 Q 1 Other: § <br /> Comments <br /> /'�'1�.�-r S f/i Qvt!s.�� _. -�8 �►•t7(.4TYav►a O,� �t_e��rt1,�0 ,�. <br /> Inspection Form Included: <br /> Comments Included:Q — -- ------ - ` 6$qb}� <br /> Busin as Reog-m#ature Phone Number Inspectots Signature Phone Number <br /> INSTRUCTIONS ON BACK Correc Incorrect: tr X A Ah P l P 2 3 62081 <br /> . White CI y CIW Yellow Copy:Operator Pink Copy:LEA ® ■ <br />