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�82�204Q�32 <br /> Waste Tire Survey & Inspection Report. Inspection Report Number <br /> r °' "'°` I1 - 1088259 <br /> CIWM81611Naw WIgQ Survey Form - Page 1 <br /> call/omla Integrated Waate Management Board <br /> Part A.Si BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- tJ Inspection Type (Fill one) <br /> Site Sufflx: I •Routine Q Re-inspection O Referral Q Observation <br /> Local /l If Referral,choose referral type(Fill one) <br /> Identifier: SE3N � A-w 1�j 0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name (J— / Inspected By Inspector <br /> Physical Address - I Q �� <br /> 2 /91 / —/e6 !�] <br /> Street Inspection Date " <br /> 9 / =0 ,5 MO <br /> ra c-�-� C.4_ 9_sz t2 I <br /> City State LIP Code Time In _ Time Out <br /> Business Rep Title � :i I I Q AM �-I �',� Q AM <br /> L_i_ �I O PM QPM <br /> iu <br /> Operational Status Tire Type Business Role Storage Type <br /> 5 (Fill one only) - (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> The Count(Whole/PTE) <br /> r I '0 Active 0 Passenger 0 Generator Q Outdoor <br /> D Q Closed O Altered <br /> GPS Latitude O Hauler Is Indoor <br /> .c_.'O Q Inactive Q Truck <br /> Longitude - O Planned O OTR O End-Use O Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repair Q Trucking Fleet O Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body 0 Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture Q Shredder Q Other I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Notice of violation Q Extension <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Comptlance Deadline <br /> O O PRC§42956-Registralion(Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O O 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX <br /> O Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O 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 /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> O Q Other: § <br /> Comments <br /> �OY�+FYntC./—�i.Nt-c ,_o.t_ ,_.-/�W�tO-c(c.� /%",/ _��— _ 1 i�.Q.H).t.�/. LV 6 V!�__�T7..TY_I_S_ __8l C.6Y►may[-h3���. <br /> O <br /> Inspection Forth Included:Q <br /> Comments Included: - � � `-�`8 Q�-43 <br /> Busines p's-Signatu Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK orre t: Incorrect1EjXjAjMjP[LjEj 1112131 62081 <br /> ■ White Copy.CI Yellow Copy:Operator Pink Copy:LFJ{ .. ® ■ <br />