Laserfiche WebLink
080159040004 <br /> ■ -eoe_ <br /> Waste Tire Survey & Inspection. Report Inspection Report Number <br /> ,r <br /> State o181(ornia Survey Form - Pagel .. I - 1 01 4 5 9 9 <br /> States Ca(New OaoG) <br /> Califomia Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- h Inspection Type (Fill one) <br /> Site Sutfix: 1 3 V �5d 0 LoLl L * <br /> Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: , I fit. Q CHP Q CIWMB Q Complaint .Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> C. '1�'�D-q�►`'O`er <br /> Physical Address (/ ✓� V� ER <br /> 11 1 oo vi fwd I a -- <br /> Street (�'t� <br /> V 95 a ya I Inspection Date O Q O r( <br /> City State ZIP Code Time In Time Out U <br /> Business Rep Title m O AM O AM <br /> 17 v (`r ��(jp _ [I]' ET-1 O PM :FT O PM <br /> L /( QJ r Operational Status Tire Type Business Rale Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> U t I I I I ai O <br /> W� Active I 0 Passenger ®Generator ' 0 Outdoor. <br /> O O Closed O Altered <br /> GPS Latitude mLl O Hauler ®Indoor <br /> O O Inactive (a Truck <br /> Longitude - O Planned O OTR End-Use ®Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repair ®Trucking Fleet O Government O Retreader O Dismantler. O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture O Shredder O Other I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> OM HAULING AND MANIFEST REQUIREMENTS <br /> O O O Notice Of Violation O Extension <br /> PRC§42951-Waste Tire Hauler;Registralion 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 O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / 11:1 / m <br /> O O 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90.days. (Required for NOV or FXT) <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements.for Registered Waste Tire Haulers O Referred!CIWMB Enforcement <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§.18462-Manifest System Requirements.for Tire Dealers or Waste Tire Generators ®In Compliance • No 1/iolations <br /> O O Other: § <br /> Comments. ,•nttb`l n jn5 - haCjUj-14 ascs ov- Gtr _rr1Ve f <br /> YQ;ivec�Q der✓i 1 l � ri - T�,�� � • oV_ 01�13,00614' <br /> L s+ fvvi ✓► ew.eo( a N V i D t L ofd d . <br /> Inspection Form Included:Q <br /> Commentsncuded:O n3l —4 a(I a " <br /> 6 <br /> Business Rep's Signaturji Phone Number Inspector's 61griature. Phone Number <br /> INSTRUCTIONS ON BACK I EjXj A M. P L � 1 2 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />