Laserfiche WebLink
Q8206048L38 <br /> Waste Tire Survey &. Inspection ReportInspection Report Number <br /> State of California <br /> cIWMe161(Naw06104) Survey Form Page 1 1 3 - 1. 0 7 9 2 5 0 <br /> Call/omla Intapntad Waste Mariayemant Board <br /> Part Ac-'Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> ' TPID- Inspection Type (Fill one) <br /> �. Site Suffix: i Routine Q Re-inspection Q Referral Q Observation. <br /> jLocal If Referral,choose referrattype(Fill one) <br /> Identifier: Sj¢/V TQ/k�►w.c.�jJ �N� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Ly /20 ,�s.�to ay.-.a«�eis� 3 `� - / O / �I�,9.t t r�.g,¢oF.✓ I <br /> Physical rens <br /> I 3�3� W yp5c�rr•�, .4ve , - <br /> Street / C-..+ q53 Inspection Date <br /> L <br /> ___ <br /> j City tate ZIP Code Time In Time Out <br /> Business Rep Title mm 0 AM 0 AM <br /> L�J'm0PM m'm <br /> PM <br /> -" - — -- - - - - ------ Operational Status The Type - •Business Role :Storage Type <br /> Tire Count(Whole/PTE) I �1!� 0 ; (Fill one only) (Fill all that appy) (Fill all that appy) (Fill all that apply) <br /> Active Passenger 0 Generator Outdoor <br /> GPS Latitude . I C Q Closed Q Altered Q1 Q <br /> Hauler. Indoor <br /> C Q Inactive 0 Truck <br /> Longitude I . — ` 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 0 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 ENFORCEMENT STATUS <br /> V AUL G A ANIF -S R QUIRE EN <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Q Notice t?f Violation Q Extensio <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-RegistratioNDecal 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 DCT) <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 In Compliance - No Violations <br /> Q 1 Q Other: § <br /> � Comments <br /> �o <br /> Inspection Form Included:Q <br /> Comments Included:Q - — ---- -- ..��-- — <br /> Business Re ' nature Phone Number Inspector s Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK orrect: I corretat: R A M P .L 1 .2 3 <br /> ■ White Co y:CIWMB Yellow Copt.,Operator Pink Copy.LEA ® ■ <br />