Laserfiche WebLink
07312040434 <br /> rte <br /> Waste.Tire Survey& Inspection Report , Inspection Report Number � <br /> State o <br /> f <br /> 8' Survey Form - Page 1_. 1 8 - 10 7 3 5 5 5 <br /> (New <br /> CIWMB <br /> California Integrated Waste Management Board <br /> 'art A-Survey BLUE OR BLACK INK-PEN <br /> Business Profile Inspection Details <br /> TPID- 11 I I I n I / - O / Inspection Type (Fill one) <br /> Site Suffix: 11 11 Il 17 ®Routine Q Re-inspection Q Referral Q Observation <br /> Local I If Referral,choose referral type(Fill one) <br /> Identifier: �a `n � ,, II Q CHP Q CIWMB O'Complaint Q Educational Visit Q Other <br /> Business or Facility Name J <br /> l Mo-,,,, <br /> ( Inspected By Inspector <br /> Physical Addr O I LLfi � <br /> Street <br /> Inspection Date <br /> Business Rep Title State Zip ode Time In Time Out <br /> 0 AM <br /> ' <br /> 70AM•PM MOPM <br /> 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). <br /> t ' I 0 Active ®Passenger ®Generator ®Outdoor <br /> llI 0 Q Closed Q Altered <br /> GPS Latitude I�� � _I� Q Hauler Q Indoor <br /> jf <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 ®Other 4 +�r <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facilitytrris+t.tr,IENT STiA1Tl1S <br /> rV,i=A.LHAULING.ANID,�M AN I F.E$1TkREQU I R E M E NTS <br /> Q QQ Notice Of Violation Q Extension <br /> PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date 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 EX7) <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 fo <br /> Enrcement <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: § <br /> Comments �j <br /> /� 1(�„•,�' �per- }mss�t>�- 'A. 0�f� <br /> �s—zcpan n�sccct—o?Yr7 f_( u N� ! oftf,H' <br /> t <br /> Inspection FormIncluded:Q % L� <br /> Comments Included:Q X ( � 2 3— <br /> Business <br /> Business Rep' Signa a Phone Number - Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK orreet Inorr <br /> cect: I EIXI RIMI P I L I EI 1112131 62061 <br /> ■ White opy:C Yellow Copy.Operator Pink Copy:LEA ■ <br />