Laserfiche WebLink
Waste Tire SLy & Inspection Re oro Inspection Report Number <br /> State of California <br /> Aar CIWMB1811 Waste <br /> Survey Form - Page 1 I 1 - 1088277 <br /> California Integrated Waste Management Board _ <br /> PartA-_Survey T- _ BLUE OR BLACK INK PEN <br /> Business Profile ';Inspection Details a <br /> ' Q inspection <br /> Site Suffix: U 9Route QReinspection QReferral' — QObservation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identifier: J G'CN <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected B <br /> L a Ck r p Y Inspector <br /> L .}L-rr_1 _ A;.t o kcRA71r mer ✓Ice�I . —_ <br /> Physical Address — 1 07 , I K r>��I;;1 n L,,-1 C cn <br /> ,Street -� Inspection Date j O <br /> CA 9523 <br /> City — State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> t' n <br /> 0 PM _ 0 PM <br /> Operational Status Tire TypeB nisu ess Role Storage Type <br /> n M; (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> `� ® Active Q Passenger Q Generator Q Outdoor <br /> OSSEO: <br /> -10 <br /> Latitude Q Closed Q Altered <br /> PS El.-I =1„ � Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> Longitude — 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 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 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 Date <br /> FF1Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB ... ., H .�--- / m <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/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 <br /> S In Compliance - No Violations <br /> Q Q !I Other: § J <br /> Comments ' <br /> V,GL'rtY-Lc _l1�`�.-�-e..c'�%o-nT orr`nrC,3-A cAe <br /> ��*cd Ap cr,x Irc:� vre-1 on- i e . Fc, c.I�r . �,_e;,_ i n ' <br /> A,- Ife r .r�,o y,a� . GTL rr^c,,n I� �� K-o/0 10 e-n <br /> \.j rl,`' n '- '�fl( �,.J,:_�x)1'('` �.�i' \Il r, :�.�, _ ;Y- ,f - O i^i_ <br /> Inspection Form Included:. Q, I <br /> Comments Included: Q Business Rep's Signature Phone Number - iaecto's Sign—1ns <br /> � atur - Phone Number y <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X � AMPL I <br /> e I 2 3 62081 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />