Laserfiche WebLink
07319040155 <br /> 10 jMWaste Tire Survey & Inspection Report Inspection Report Number <br /> state of Callfomla <br /> CIWMB 191(New 04104) - .Survey Form --Page 1 14 - 10 7 3 5 5 1 <br /> callfomia tntegntad Waste Management Board <br /> Part A-Surve BLUE OR.BLACK INK PEN <br /> Business Profile Inspection Details. <br /> TPID- Inspection Type.(Fillone). <br /> Site Suffix: 1 13 17 10 1 O 1 8 I ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type.(Fill one) <br /> Identifier: 'ro0. µN (farV,--}^-V Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name / Inspected By Inspector <br /> I f�I.G��CI YYl �--f <br /> Physical Address <br /> Street <br /> S,6ck+v--- (2-A Inspection Date <br /> City State ZIP Code <br /> Time In Time Out <br /> Business Rep Title m'F-1-1®PM IE'm ®PM <br /> __ _ I Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ) 1 f -71 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> .,. <br /> _ _ ®Active ®Passenger ®Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude � Q Hauler Q Indoor <br /> QInactive ®Truck <br /> 1 <br /> Longitude - � I-F IT1�10 Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) L <br /> Q New Tire Dealer Q Auto Repair ®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 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder. Q Other I 1 <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility EN�ORC-EMENIT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation <br /> Q Q Q Extension <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 <br /> MI III / m <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 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/C-IWMB 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 /> —VVCe 1�`_ �can'rs r tuner DTs )rte ca 7 aAr+—r2e�t+a C �—"44-r zy've ,.1-e. <br /> Inspection Form Included:Q /J,y` L g_�6 <br /> Comments Included:Q n z <br /> �� �'� <br /> Bus ness Rep's.Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Irlcorreet: 62081 <br /> EXAMP'� E' 1! '23 <br /> . White Copy:CIWMB Yellow Copy Operator Pink Copy:LEA ■ <br />