Laserfiche WebLink
o$ s;o�0007 <br /> err_ <br /> Waste Tire Survey & Inspection ReportInspection eport umber ■ <br /> ;r <br /> State Survey Form - Page 1 11 - 1 0 7 8 1 0 9 <br /> CIWMB 181 stew nage Y <br /> Califomla Integrated Waste Management Board <br /> Sart A-Survev BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I O q Ck q o J 12 - O t�l Inspection Type (Fill one) <br /> site Suffix: l l JI 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local I T If Referral,choose referral type(Fill one) <br /> Identifier: San Tbck9u1n Coun-t1v__] Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Lo_ka -f►re_Ser_��ce�_zr�c. I® _ <br /> Physical Addrdss Q 1 �Kr151; ,a0_I_UAAS� <br /> d�►_AvP I <br /> Street Inspection Date <br /> LL 0-d CA- Time Out <br /> q52`{o� l <br /> City Sfate ZIP Code Time In <br /> Business Rep Title Q AM Q AM <br /> / mm � <br /> OWflff Q PM m QPM <br /> __Jt <br /> I i 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 /> The Count(Whole/PTE) <br /> r 1 Z C! O Active ®Passenger 9-Generator . ID Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> -- -- �— <br /> O Q Inactive Q Truck <br /> I- I I <br /> Longitude - I J - I — I 1� Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that applllly) 111 111 <br /> 0 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 <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 ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 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 /> Q Q PRC§42956-Registration/Decal,in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / 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 O <br /> 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 p Referred 1 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: 1 <br /> Comments �Qu�'Q Inq�`+lOY1�CY?Uffrte(� IS �qlQ �Ol WI c U�¢$ r)_Q _ej <br /> 'l*o•'-Tt�ein' �roJn� <br /> weLe re�wIaeC1 ., ��uta ec}.u�s No v►A�c�}�_an�o�_cafeaS <br /> Inspection Form Included:Q <br /> Comments Included: — <br /> _f, _ o :� 468-3178 <br /> IB Busine Bp's Signature "-phone umb ctor s Signature _ Phone Number <br /> X� d j I R I II I 6208' <br /> INSTRUCTIONS ON BACK�Corre Incorrect: X A M P,�I EI: 12 I'2131 <br /> . Whit Copy CI M Yellow Copy:Operator Pink Copy LEA <br />