Laserfiche WebLink
88227040214 <br /> Waste Tire Survey& Inspection Repo rti Inspection Report Number - <br /> �o St meiie of alRomla Survey Form - Page 1 1 3 . 10 7 9 1211 <br /> CMINB 181(Nar OClDa) <br /> Calilomie Integrated Wasu Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID• Q _ Q Inspection Type (Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> LocalH Referral,choose referral type(Fill one) <br /> Identifier: S An To CSC,Lit n \+QUnt Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 1 <br /> Physical AddressJ ss 3 -1 I Q j Lkr;��_(� L✓uC�1S _j <br /> X36 Per_�dfrnghC2 (fit. I <br /> Street <br /> Inspection Date <br /> Ga'n C-h q�2Oki <br /> rty State 2't?Code Time In Time Out <br /> Business Rep Title O AM O AM <br /> m' O PM O PM <br /> Vc►�s�ieJl_P1ant_M._ r_.—_� Operational Status Tire Type Business Role Storage Type <br /> 1 (Fill one only) (Fill all that apply) (Fillall that appy) (Fit all that apply) <br /> Tire Count(Whole/PTE)I <br /> 0 Active Q.Passenger 0 Generator . Q Outdoor <br /> Latitude Q Closed Q Altered <br /> GPS Q Hauler Q Indoor <br /> D Q Inactive 0 Truck NSA <br /> Longitude - Q Planned 0 OTR Q End-Use 0 Container <br /> Business Type (Fill all that apply) - - - - <br /> Q 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 0 Other I_st4tQ4 Pic e`rsAn_ <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENF_ORCEM_ENT STATUS <br /> V A HAULING L)MANIFEST REQUIREMENTS 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 /> iQ Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / I[] <br /> / 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 .0'o l CT) <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 Q Referred/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 0 In Co pli ince - o Violations <br /> Q Q Other: § ` <br /> Comments p_ 1-f!6tt101 1�OrQT_r-►•cCi1S�C31P—prs.rn► �. tJo +►rte s+o��tan-sife_.�a�osk :1�p1.oy-i- or_ <br /> heexl r�c;nre 1_1 >�IIo1A clrS o� i <br /> Inspection Form Included:Q //f- `xq) <br /> Comments Included:Ql - U oi'Og'?jsl� /_ e' <br /> usiness Rep' natu Phone Number In rs.Slgnat Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK In orrect: E X A M P LIEJ 111213 <br /> ■ Whit Copy C B Yellow Copy Operator Pink Copy.LFA ® ■ <br />