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07312040436 <br /> eu <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> Cl=11(Ne� Survey Form - Page 1 1 9 - 10 7 3 5 5 6 <br /> clwMa iei two.,two�l y <br /> "ifomle tnlegnted Weera Management Board 1 <br /> Part A-SurveyBLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / Inspection Type (Fill one). <br /> Site Suffix: I / C7 lil - 0 ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) - <br /> Identifier: TQ4r� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 a u B Inspected Ins <br /> Stoulchv.� f � P Y Inspector <br /> ��fSSciyyt \��-�°=5�l�Ll-_o��.(•o�kfi�'^ J � - <br /> Physical Address�-J 3 9 ITO I/] L <br /> 3 13 ► A <br /> Street q <br /> Inspection Date <br /> State Z!P Coe� rijpZ1 1 <br /> rt Time In Time Out <br /> 6 AM 0 AM <br /> Business Rep Title m m O PM -m v PM <br /> - <br /> Operational Status Tire Type Business Role Storage Type. <br /> I (Fill one only) (Fill all that apply) (Fillall-that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) 6 D <br /> t r ®Active ®Passenger ®Generator Q Outdoor <br /> Latitude L 1 .I-I I I I O Q Closed Q Altered <br /> GPS Q Hauler Q Indoor <br /> QInactive 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 (0 Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other I I <br /> _ - I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFOROE ENT STATUS <br /> V A HAULING AND MANIFEST R QUIREMENTS Q Notice tJf 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. Eompllance 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-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Requi ed 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 I -IWMB Enforcement <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities _ <br /> Q Q 14 CCR§16462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In C-ompllance - No violations <br /> Q 1 Q Other: § <br /> Comments <br /> I <br /> Inspection Form Included:Q <br /> Comments Included:Q S�6T X06 Z3 <br /> Busi +kA6P%1(X1ghatui _ Phone Number nspectors Signature Phone Number. <br /> INSTRUCTIONS ON BAC C "ire correct: E X A M'P L E' 1 2 3 62081 <br /> ■ White py r Yellow Copy Operator Pink Copy LEA ® ■ <br /> I <br />