Laserfiche WebLink
Waste Tire SW,. y <br /> & Inspection Repo Inspection Report Number ■ <br /> State B California Survey Form Page 1 11 - 1088030 <br /> CIWMB 181(New nage 9 <br /> California Integrated Waste Management Board __- <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> , <br /> TPID- � � Inspection Type (Fill one) <br />} Site Suffix. ( ?j 8 _ r Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local <br /> Identifier: A n 7©a ,U 1 r1 C OU nt If Referralchoose referral type(Fill one) <br /> O CHP O CIWMB 0 Complaint Q Educational Visit O Other <br /> Business or Facility Name : _ Inspected By Inspector <br /> Conver �n�.]..._ L-1-l" <br /> Physical Address � J - <br /> 6-_ r�stl� L.u c aS <br /> I <br /> L- 633.__ Sn �an. _ •te <br /> .......... <br /> -� <br /> Street Inspection Date i / <br /> �-t-ockto n CA 952)3 <br /> Code LLI <br /> ut0 AMCiiy - Stag 7Pi=Codi Time In 4 Time OBusiness Rep Titl . -1 O PM ��� F QPM <br /> M, „! � �r a z [ � ��„-•� �w.,,,, �+ ,ti��, d.�,; � �u�, Operational Status Tire Type 1 Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that aPPIY) (Fill all that apply) <br /> . .. ��.1"� l��✓�''#�a a'�"SY <br /> ACtIVe Passenger Pr C)� Generator 0 Outdoor <br /> O Closed <br /> SPSLatitude O 0 Altered <br /> i <br /> Q Hauler 0 Indoor <br /> `—�_--7 • ` —°--� O Inactive Q Truck <br /> Longitude - - Q Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> ­_ <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body O Car Dealer O Collection O Crumb Rubber <br /> Q Service Station O Hauler O Agriculture Q Shredder Other Pa r C O(1�/2r1 fl <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS_ <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation Q Extension <br /> PRC <br /> Hauler and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O 1 O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / FF / M <br /> Q I 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 EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities - -_ <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> I <br /> Q Q Other: § <br /> Comments V-ou��cw_ 1m-,p( ion bxr orryaA _Ab Ii" e ” Ojjoujny �-JAS__(?0� e <br /> s, . <br /> b -bre-s U'e_-� )�15vh UyG —CA re Co . or A-Ire <br /> � L�1�_ �cxSte �a5ed ��r r�r�oya� . �tiJT rrXan►te _ OnVolce-, kAc%ye <br /> QrS VJ2Yz 14PuJC'C _I�f \li'l�A'�lOr� --- (7 01`_ <�1 --Ca�YGerr) <br /> gl <br /> Inspection Form Included <br /> c s Ftep` /Signatuee - Phone Number r/ _In "ector s Signature "r Y� Phone Number 1 <br /> Comments included <br /> Bust {{ s/ A'.VP j_ <br /> INSTRUCTIONS ON BACK "Col`rect:® incorrect: Lfi '' I E 3 62081 <br /> eWhite Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />