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M <br /> Waste Tire Survey & Inspection ReportInspection Report Number <br /> state Of cWM818>Kam,a Survey Form - Page 1 I1 - 1088041 <br /> CIWMa 1a1(Naw 00100) y 9 <br /> Calltomta Inta9rateA Waste Managemem BoarE <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> I Inspection Type Fill one <br /> ) <br /> Site Suffix:Tpip. Routlne QReinsp <br /> ection Q Referral Q Observation <br /> Local ( If Referral,choose referral type(Fill one) <br /> Identifier O�QQa1Llf1 COLLQ CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name JJJ <br /> Inspected By Inspector <br /> I MN <br /> Physical Address <br /> 1950 S- l�+�go�, kpcw <br /> Street ® / <br /> Inspection Date <br /> ci?y Stats Z!P-Cor,-9 Time In Time Out <br /> Business Rep Title —T—' F I Q AM �[�—� Q AM <br /> n 1 <br /> !:!o :O i*PM 3 , I g 5 I ®PM <br /> A�'a`1 "'' "- - .- c4"'-" -— ' Operational Status Tire Type Business Role Storage Type <br /> Tire Countoq�TE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ®Active •Passenger ®Generator Q Outdoor <br /> .O Q Closed Q Altered <br /> GPS Latitude • _ Q Hauler Q Indoor <br /> .0 Q Inactive ®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 Relreader 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 �� (K(y�� '_t►_F'eA <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 Data m /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 DCT) <br /> Q A 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 Vlolations <br /> 1010 Other. § _ <br /> Comments 11 1 r r I n e• <br /> 't_,'T/,t1`e.Ab_SS�f et_1 --WX—&0Ckk11_0Q .&1. W1U���5 1».J S_A: QfG nOItIV- �Cu�w <br /> Brad o8 1111 -b 1171 oll it <br /> Inspection Form Included:Qyxx/ <br /> Q S <br /> Comments Included:• y �C__S `r6— "LyU—J rJ—O <br /> ass p•s nal Phone Number( Inspectors S gnature Phone Number <br /> X 0 v ®® 62081 <br /> INSTRUCTIONS ON BACK Correc:� Incorrect: � X A � P L E ! .2 3 <br /> ■ White opy.C B VellaW Copy.Operator Pink Copy.LEA ® ■ <br /> I <br />