Laserfiche WebLink
08234040299 <br /> Waste Tire Survey & Inspection ReportInspection Report Number <br /> '° state of 161(N.. I 1 -- 1088127 <br /> ClWMB W.M. .ag Survey Form Page 1 <br /> California Integrated aete Management Board <br /> Part A-Survey' BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: <br /> Routine Q Re-inspection Q Referral Q Observation <br /> Local C ..JO u 1 Ou"_ r If Referral,choose referral type(Fill one) <br /> Identifier: :5qn - � �Ty Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> P Fosi-2r LuMb�r I _ <br /> ' Physical Address 3 � <br /> L__2_9 11 M 4g gi o c irde I <br /> Street Inspection Date Q ? Z ( I Q 8 <br /> ods <br /> CA 9.5Zy/I _ <br /> ty Stjte ZIP Code Time In Time Out <br /> Business Rep Title I :O AM i— 1 O AM <br /> J O PM I-- --–].li—I---I O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> f f �Active Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 40 Truck N/R <br /> Longitude – Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber 1_- <br /> 0 Service Station Q Hauler Q Agriculture Q Shredder S Other �Lt�tm VC r YQrd_. I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use FacilityENFOR_C-_E-MENT STATUS <br /> V M HAULING AND MANIF.ESTREQUIREMENTS 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / IE <br /> Q Q 14 CCR§1!3459.1-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§16459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required(or NOV or EX 1) <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/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 Yiolatlons <br /> Q Q Other: § <br /> Comments <br /> QoIre. �ns�ect±c�n—�¢,r�oc�ned this dates -tie. o1low�n9 was <br /> _n_a ed—T-_-ct6A%%__users li t'_f int mon_-T-1.r_ or w.as_+e_*ire—r_e_moval— <br /> [ese-c�iC GSL—mc>In��as� Ye_bean r_4;fQ!� w¢.� <br /> _q�g1VQ_K*,—tCor v'�.eta1_ _ . _ --t_es+ No_Uol o-r qr-Gs—pF co_oterr7 <br /> Inspection Form Included:Q 4244 <br /> Comments Included:Q �ure <br /> ��3 <br /> Busineone Number Ins ctoYs Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: IncoXrrect: E R M P L E1 111113 62081 <br /> ■ White ,opy CIW Yellow Copy:Operator Pink Copy.LEA ® - ■ <br />