Laserfiche WebLink
08i29041Q84 <br /> Waste.Tire Survey & Inspection Report Inspection Report Number <br /> cmlMe tet(Now <br /> atete°rcaiNow 0,1404) Survey Form !. Page 1 1 9 . 10 7 2 81 4 <br /> caliromia Integrated Waste Managemem Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: . 0 9 3 5 3 0 1*Routine Q Re-inspection Q Referral Q Observation <br /> Local <br /> H Referral,choose referral type(Fill one) <br /> Identifier:IdentiT <br /> AnJ O / (�OL,v� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility <br /> Gf +Name <br /> � Inspected By Inspector <br /> Physical Address <br /> iI Street 3330 IJ q-kD A-47- fQ� I ---------- --------- <br /> Lk 4ew ef.4 <br /> L 2 Inspection Date r-(i G1Y v CPJt <br /> Cid�I O G StateIPCode Time In Time Out <br /> Business Rep Title O AM O AM <br /> �"�— ... __IA►✓L.._— J i m <br /> MOPM m' O PM <br /> -- <br /> 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 /> Tire Count(Whole/PTE) r I r I r/ g <br /> 40 Active Passenger 0 Generator 0 Outdoor <br /> 0 Q Closed Q Altered <br /> Hauler <br /> GPS Latitude Lam_,I--_I I Q Q Indoor <br /> J <br /> Q Inactive Q Truck <br /> Longitude - FT- 71-FTI-T-7-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 Q Trucking Fleet .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 ENFORCEMENT STgTUs _ <br /> V ' A IN AND MANIFEST RE431111IREMENTS Notice Of Vlo tion Q Extension <br /> i <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 Dea line <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 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 Referred/GIWMB 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: §, L <br /> comments � �G—iNSO«h�+ 13 o-T (1. O1L� <br /> o ✓ i2rs—n�Cor�t.ea-+�3—/lb�TciQ <br /> Inspection Forth Included:Q G wl 2-M� <br /> Comments Included:Q _ rP <br /> Business Re 's 9griature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK e• 9 1:0• t E x a M P L E 1 .2 3 62081 <br /> ■ - While Cy CIW!8 Yellow Copy.Operator Pink Copy:LEA ® 0 <br />