Laserfiche WebLink
07319040137 <br /> Waste.Tire Survey &.Inspection Report Inspection Report Number... <br /> ■ 1 <br /> N <br /> State of Callfomia <br /> crwMate""04104) Survey Form.- Page 1 _ 19 - 1 .0 7 3 4 7 3 <br /> calitomla Integrated Waste Management aoard. <br /> PartA-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection.Details <br /> TPID- Inspection Type.(Fill one). <br /> Site suffix: I i y 5 3 1 0 1 .2 . D <br /> ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier:. .:-TY�cri...n � q/•• Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address X41 - F/To P <br /> L <br /> 11— 33 �•► Sc�4 s i �fyv� <br /> Street <br /> Inspection Date <br /> 47,52 03, i <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title ®AM <br /> :F1 1OPM LL 1: 0 PM <br /> Operational Status Tire Type . Business Role Storage Type <br /> I <br /> { (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all That apply) <br /> Tire Count(Whole/PTE) <br /> ®Active Q Passenger ®Generator: Q Outdoor <br /> Latitude O .Q Closed Q Altered <br /> GPS ��• Q Hauler Q Indoor <br /> O Q Inactive _ Q Truck <br /> Longitude _ Q Planned Q OTR Q End-Use. Q Container <br /> - ---— --=--- <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 ®Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> --- ---- <br /> V A HAULING AN DI MANIFEST REQUIREMENTS Q Notice Of violation Q Extension <br /> O 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 /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / 11:1 / m <br /> Q Q 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§16459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NO'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 1 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 1 Other: § <br /> Comments <br /> �cr►s_1,��4•,v`e•tM c,Rx�,_�,P� �5 t tj,e..r/ �-Eirc e1i�Pasa.Q. �n ii�S GbS�-,�rsv <br /> Ogs_tl.eT�K._V_O��ts [t lnn1�(X LS spur• LL(LtN_r_Z_T_L,.S_F_, M_ Q 'tt', p.V.r,`�y`r. <br /> Inspection Form Included:Q <br /> X L (o Z <br /> Comments Included:Q - - <br /> Business ep's Si ature Phone Number nspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK C►orrect�Incorrect: X a P L1E1 1112131 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />