Laserfiche WebLink
09112040008 <br /> cre_ <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of CaliTomla SurveyForm - Page 1 Il - 1088380 <br /> C (New 00104) <br /> califomla IntegraIWMBted W181aste Management Board <br /> 'art A-Survev BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- - Inspection Type (Fill one) <br /> Site Suffix: I ( I T J g g.I f I R Q <br /> , ,. � ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: O Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility ame Inspected By Inspector <br /> S. LaCu sF -e _ T <br /> (ysJal Address � q 1�eA e r- ^'fir V`�f I Inspection Date /`� 2 <br /> City V V GV J State ZIP Code Time In (/ i7 Time Out _ <br /> Business Rep Title / ®AM O F R1 O AM <br /> V VcV�� :i PM I �I ®PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 1 f v (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 45Active Q Passenger 0 Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ®Truck - <br /> Longitude - Q Planned Q OTR Q End-Use ®Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ®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 I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORC-EMENT STATIUS <br /> V A HAULhNGtE1ND4MAhr.etobYi c:kU IREMENi <br /> Q Notice Of Violation Q Extension <br /> 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 § n <br /> Q Q 14 CCR§16459.1-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 FXT) <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 f 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 Q Other: § r �,t .y��" �/ •� I.. .{ ,�/ IMS ate_A <br /> Comments �tfLT-jfn p i�l�rQ� S 1 ntS IJIL�-r ,t.I�(•U__'l 7FtL__JV��)�_tl�t�F r <br /> �ACtI.� _ti-l/St�S"_— JLrC-0 TrG r $P ✓iCe _ a+ <br /> Maht;Fe..S_t"Arm's vigwed . LAsi- on 3/a3 v5'. No woste_ <br /> -fi✓es oh_Si e . No vro fine L . <br /> Inspection Form Included:Q <br /> _ ksn_ 4—Comments Included:Q —usiness Repture Phone Number Inspecto s Signature Phone Number . <br /> INSTRUCTIONS ON BACK 1EMAJAIPILIE1 1112131 62081 <br /> ■ White Copy.CIWMB .Yellow Copy Operator Pink Copy LEA ® ■ <br /> I _ <br />