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07312040433 <br /> Waste Tire Survey & Inspection Report inspection Report Number <br /> °Q 5""et (N Survey Form - Page1 1 1 - 1 073557 <br /> CIWMB 181(New 04!04) Y <br /> callfumla Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- c, q Inspection Type (Fill one) <br /> Site Su..: � � / 9 ii 3 / S � � O Routine Q Re-inspection Q Referral Q Observation <br /> Local It Referral,choose referral type(Fill one) <br /> Identifier: i 00. u ytn Cyn4 �Y Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> _ <br /> Physical AddressFmol m L,A ,- <br /> i3oe.t��t <br /> -3 3 �,.+o �,�l�r C► <br /> Street <br /> Inspection Date <br /> t_—S 4 5 zl z <br /> city State ! od a Time In Time Out <br /> Business Rep Title m 0 AM 0 AM <br /> ' m®PM LLI:m O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> The Count(Whole/PTE)` I L (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active ®Passenger 0 Generator Q Outdoor. <br /> Latitude —��O Q Closed Q Altered <br /> GPS Q Hauler ®Indoor � <br /> O 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—0 Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body ®Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q 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 <br /> 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 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 (Requir for NOV or FXT} <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/C-IWMB 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 C-ompliance - No Violations <br /> Q 1 Q 1 Other: § <br /> Comments J" n <br /> �L.t4FY�iC. Crl-t'-�c�t-tclr_+ bl_l�-111S�.�a*R--��.(�t$—�.1/-!-`.��Ci r_rf T•c 1-r�..�at <br /> heuJ_".—'DTs o tt/avra -� to_y- <br /> Inspection Form Included:Q <br /> Comments Included:Q , <br /> Busine s R 's Ig to hone Number nspectors Signature Phone.Number <br /> INSTRUCTIONS ON BACK Correc ncor x 1EVARRILE 1 2L3 62081 <br /> . Wh a Copy 6S Yellow Copy.Operator Pink Copy.LEA - ® ■ <br />