Laserfiche WebLink
Ir. action Report Number <br /> Waste Tire SL@e)* Inspection Repor <br /> SQ1 f State B California I 1 1088410 <br /> Cgrated 1(New Ma1ge Survey Form - Page 1 <br /> California Integrated Waste 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: � 3 I - 0 Routine 0 Re-inspection 0 Referral Observation <br /> Local ,may If Referral,choose referral type(Fill one) <br /> Identifier: Sotr) TOC'9LOYl COut ► 1 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> F ok Cal dor n i ca C OC p . I 9 _ f <br /> Physical Address , 3 I I Krls-t'ian Lucas b <br /> 1 1910 r-. LOAV)rop Rd- 1 <br /> Street <br /> Inspection Date O Q <br /> i L.a4n fop CA 95,3_30 <br /> Cif, State ZIP Coo Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> S+ores �� ' ( e PM Q PM <br /> R)ao Ga►f G Xa, Gn r*ro4e - — '-Stora <br /> Operational Status Tire Type Business Role ge Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active 0 Passenger Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> p 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) ' <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber jpCeC.oS�-/ PreS 1 fesseck <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ® Other I COhGf-eke. t3iSar4asf Uri <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 Other: §,_,_ - - <br /> Comments Rov+lnQ m,_5oe_+io n -` ' rv%ed -thi,5 dgle hire �ollOw in- wa <br /> n4ecd . Approx. 1 used Fires tAor on-s;+e. ��c�lit� dae ra s Crctr l� <br /> loader, orGder �orkli�} marl�t-t , rea.du m►X rfoCW yj ton—A *on <br /> Fa�,i1_�'t•.� u�s�� r1 ~�ndu�r�t�l -r►re Nnr+ham ��� . �or��o�-t <br /> nspect16 Form Included: 0 <br /> Comments Included:�!— - - - - -=- - - - - - <br /> Business Rep's Signature Phone Number' Ins ctor's Signature Phone Number <br /> —_ -- - <br /> / 62081 <br /> INSTRUCTIONS ON BACK Correct: �/Incorrect: X 1 ?% 0. W► P L E 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />