Laserfiche WebLink
08206040146 <br /> evv <br /> Waste Tire Survey & Inspection Report . Inspection Report Number <br /> State CIWM of California Survey Form - Page 1 1 . 7 - 1 0 7 9 2 7 0 <br /> CMVMe 181(Na.Dago) <br /> California Integrated Waste Management Board <br /> 'art A-Survev BLUE OR BLACK INK PEN.. <br /> Business Profile Inspection Details <br /> TPID- 1 / I I7_ IS I L f 1 - D / Inspection Type (Fill one) <br /> Site <br /> Site Suffix: Il )I 7 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: T llf Q CHP Q CIWMB .Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name . <br /> Inspected By Inspector <br /> L o ,�K Tiut�,�,•„r9 I _ III <br /> Physical tAddress <br /> 27fJ� G Lp-Ui_S�—�✓e <br /> Street a <br /> Inspection Date <br /> L—CA .r o CR 9533 <br /> City State ZIPode Time In Time Out <br /> Business Rep Title O AM O AM <br /> mO PM m F71 O PM <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE), <br /> (Fill one only) (Fill all that apply) (Fill all that apply)' (Fill all that apply) <br /> � I , <br /> v ' I4@ Active Q Passenger i Generator Q Outdoor <br /> �0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> —I--I— QInactive !Truck <br /> ILongitude - - TI.I 7 I 1 o Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <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 I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility gi r;v E- STATUS <br /> V A HAULING AND MAIREM EN_ITIS-1 in,1(7 o III II 11 <br /> OQ Notice Of Violation 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 /> 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 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 on C-ompliance - No Violations <br /> Q Q Other: <br /> Comments K/OTiv f/N /flSD(. -0H'S �a _LKs L,lL,tll`./`�/'• Nom- �' <br /> —/far:3—f_.' ew��i—baa N 7St0� /��.5 ��Wf�O Lt;.d ✓�o-�`h �'�gl_3�c,�.P_ <br /> _�r_« �c_�.,...,,i.�!/. �,Na.�-.,._�-s ✓/`e�I�.moo t/_i a_�.q-n-�I_�S—o_�(J �*c..��t.y <br /> F , J <br /> Inspection Form Included,01 <br /> Comments Included:Q <br /> usiness Re ' Ignature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK ...... Incorrect: IEIX .A I Ihp IP :L t IE I 1112131 62081 <br /> ■ W hits C y.CIW MB, Yellow Copy.Operator Pink Copy LEA ® ■ <br />