Laserfiche WebLink
08129040749 <br /> cre. <br /> Waste Tire Survey & Inspection Report inspection Report Number <br /> StateCFWM r181(Nrn'a Survey Form - Page 1 1 9 - 1 0 7 9 1 7 3 <br /> CIWMB 181(New nage <br /> Califomla Integrated Waste Management Board <br /> Part A.Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / � � O ^ � - O ,I Inspection Type (Fill one) <br /> Site SuffiX: o L f 0 Routine Q Re-inspection 0 Referral Q Observation <br /> Local If Referral,choose referral type.(Fill one) <br /> Identifier: ��yJ uCV4�ittl�h _ 0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name /1 Inspected By Inspector <br /> �Q /e T¢f s q <br /> Physical Address - lay] <br /> StrL 7-1 9 `fir' �•./.yj0_�'fi .sr I <br /> Inspection Date Q 3 Z o 8 <br /> t_ ac., ,lay, Gi4 9S2OS, <br /> City state ZIP Code Time In Time Out <br /> Business Rep Title m m 00 AM 0 AM <br /> PM m m 0 PM <br /> I 2 / <br /> _cGGS�A�J__pO.�.A� ILIAnIAdiE�__ <br /> Operational Status Tire Type Business Role Storage Type <br /> j l (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) 2 5 <br /> • 0 Active t♦Passenger 0 Generator 0 Outdoor <br /> IO Q Closed Q Altered <br /> GPS Latitude I I Q Hauler Q indoor <br /> _—L- —I t _ -I---� Q Inactive Q Truck <br /> Longitude Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 1*Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <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 IIIIENEORGEMENi STATUS <br /> V =HAULING AND MANIFEST REQUIREMENTS <br /> ion <br /> Q Q Q Notice Of ViolatQ e IOn <br /> 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 Date m / m <br /> O Q 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> O 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 /> 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 /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance - No Violations <br /> Q Q Other: §, <br /> Comments <br /> a t;�� d_,s�O „0 .ca _#-,p,3'.. ;6�i <br /> �_�, ,t/oye/�ho►cs� Gem Svcs �clor�o0 <br /> Inspection Form Included:O <br /> i <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X .A M P L E. 111'213 <br /> . White Copy:CIWMB Yellow Copy Operator Pink Copy.LEA ® ■ <br />