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07354040063 <br /> Waste Tire Survey & Inspection Report _ inspection Report Number ■ <br /> ` CtFwM181(ma I SurveyForm - Page1 11 - 1073348 <br /> CNVMe 191 New 01101 ' <br /> calMomla Integratetl Wasle Management 9oard - - -- -------- --- <br /> Pa_rt A-Survey _BLUE_ OR BLACK INK PEN <br /> !Business Profile _ Inspection Details <br /> TPID- I S`i -7i f ' - O 1( Inspection Type (Fill one) <br /> Site Suffix: o I Routine Re-ins-inspection Referral 0 Observation <br /> Local IfIf Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business;Ad--r <br /> ility Name - �(�/- Inspected By Inspector <br /> -- -- -- - - - - - 22 - / 0Physlwl ss � 1 �.J� � -- - -- l J 11 1-j <br /> I Wo <br /> i <br /> �`r L ^^ Inspection Date <br /> ?tea �j s I ' <br /> ;- c,:.,,• 7tP C:,lp Time In Time Out <br /> Business Rep Title F I O AM ' -- I Q AM <br /> I i :i <br /> 01v- <br /> .j 0PM ` 1 � 0PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ) n (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ! /J I®Active Q Passenger ab Generator Q Outdoor <br /> O 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 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 Q Notice Of Violation Q Extension <br /> Q 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 <br /> 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 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 ®In Compliance'- No Violations <br /> Q Q Other: §. _ <br /> CommentseS <br /> fire r -fr ✓i u J qJ �w I9U-WSJ LSV*` �V�r <br /> !ti <br /> Inspection Form Included:Q / <br /> Comments Included:Q - <br /> Business Rep's Si n ure Phone Number Inspector's p6fntur. Phone Number <br /> -- - <br /> INSTRUCTIONS ON BACK Correct:* Incorrect:X0q1jEjXjAMjP1L ] 2 g 62081 <br /> ■ White Copy CIWMB Yellow Copy Operator Pink Copy.LEA ® ■ <br />