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0822.704.0104 <br /> « , Waste Tire Survey & Inspection Report - Inspection Report Number <br /> CPWMB11(No. Survey Form - Page 1 ( 7 . 10 10 8 8 7 <br /> CIWMB W.M.(Newo40a) <br /> CelHornl�IN�gnted WManap�m-nl Boani ' <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPIDD D _ D / Inspection Type (Fill one) <br /> Site Suffix: <br /> Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: fj�1 ��A4-�_w` v �OJn1T.�—:Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name J Inspected By Inspector <br /> Physical Address f O �I �. <br /> 3� W. M_ <br /> Street <br /> YLI — <br /> © �Inspection Date <br /> City State Zip Code Time In Time Out <br /> Business Rep / Title O AM 0 AM <br /> Pepe —5—c- �,A- r /,�Ti�� �yp i m mOPM m m OPM <br /> ---F Operational Status Tire Type Business Role Storage Type <br /> r (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire CountWholelPTE <br /> ( ) 0 Active 0 Passenger 0 Generator Outdoor <br /> Q Closed 0 Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> D Q Inactive 0 Truck <br /> Longitude — Q Planned Q OTR Q,End-Use Q Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer Q Auto Repair 0 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- Y .._......�Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> P ' __ <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q Q 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 14 CCR§18459.1(a)(b).(c)-Tire Program ID Number from CIWMB <br /> Q 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required!or NOV or FX7) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q 0 14 CCR§16460.2-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 0 In Compliance No Violations <br /> Q 1Q Other: § <br /> Comments <br /> Ribas U (.l LtN� <br /> aJ a� ��_,f��.-l��c :-12�'-f� ys e1 [✓i L_S�» W <br /> _rrr� <br /> 0 <br /> Inspection Form Included:Q <br /> Comments Included:Q Agn <br /> 20 V2. f/fy — 4( z '9 <br /> Business Rep'sure Phone Number Inspector's Signature Phone ilumber <br /> INSTRUCTIONS ON BACK C-o? Incorrect: 62081EXAMPLE' 1 23White Cap Yellow Cop,.Operator Pink Copy LEA ® ■ <br />