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08066040006 <br /> Waste Tire Survey & Inspection Report inspectionReport Number. <br /> Sul.ms 181 fem4 Survey Form - Page 1 1 9 - 10 10 6 0 0 <br /> cnrree�e�(N.w anal <br /> c.111 rntagrated Was.ManagertwM Boats <br /> Part A_S <br /> BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID 1 3 V3 3 I - O I Inspection Type (Fill one) <br /> Site Suffix: / ®Routine Q Re-inspection Q Referral Q Observation t <br /> Local / If Referral,choose referral type(Fill one) <br /> IdeMlfler: 0. <br /> CHP Q CIWMB Q Complaint Q Educational Visit .Q Other <br /> Business or Facility N���a=mmee Inspected By Inspector <br /> Ph�ysicalAdres�ss I V -1 - F/ Qltliapp� � <br /> i sof 0 Y02 AC- I <br /> Street Inspection Date <br /> I tfJ <br /> City , StateIL Code Time In Time Out <br /> Business Rep Title I 0 AM 0 AM <br /> Q L ' 0 PM 0 PM <br /> ET <br /> � Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) I . (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> __ r l° L © ®Active ®Passenger (a Generator Q Outdoor <br /> Latitude D Q Closed Q Altered N� <br /> GPS m• Q Hauler Q Indoor <br /> D 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 IAaAa_fadw_d &0yKe <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 if 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. C-omplrance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required(or NOV or FX7J <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§184602-Manifest System Requirements for Registered Waste Tire HaulersQ Referred f CIWMB 0 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 1 Q I Other: § <br /> Comments <br /> -- A.eAe11 to .s Fu ei use S Se S <br /> tt�'e -franc d tsyPo6a-t J9DM ems _ -fir sir <br /> p t . <br /> ✓)o -tine S 6h,7 . /Vo ✓i afa c.e 7 s <br /> Inspection Forts Included:Q��4 --)_V-115_0 <br /> Comments Included:Q <br /> Busin Rep's Signature Phone Number Inspectors SI ature Phone Number <br /> INSTRUCTIONS ON BACK. t?orrect: Incorrect: E P X A M L 1 2 3 62081 <br /> ■ White Copy CIWMB Yellow Copy:Operator - Pink Copy LEA ® S <br />