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. 07312640463 <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CWMB181(Now Survey Form Page 1 1 4 - 10 7 3 5 4 3 <br /> cnvrne tet(Now o+w+l <br /> call ,; Intagated Waste Managoment gourd <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile - Inspection Details <br /> l TPID- Inspection Type (Fill one) <br /> Site Suffix: 493 <br /> 3 1114131 ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: s Cyh ��{-y Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name (� Inspected By Inspector <br /> L I forurp(y4 �1 <br /> Physical Address 3 9 / D L A` �_ � <br /> II Street � h���w� <br /> Inspection Date. <br /> city C'A 9S 3 <br /> -ztP Code l Time In Time Out - T <br /> Business Rep Title 0 AM QAM <br /> :MOPM ED EEI 0 PM <br /> _ Operational Status•Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 !' I <br /> t a s O Active 40 Passenger 41 Generator ®Outdoor <br /> ° O Closed Q Altered <br /> GpS Latitude I L L— I � <br /> I— O Hauler Q <br /> Indoor <br /> _ <br /> r r Q Inactive Q Truck <br /> Longitude - I I -I I 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 <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use FacilityENFORCEMENT STATUS _ <br /> V A I 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 /> O Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m <br /> Q O 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> iNOV <br /> Q Q 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Requred for or FX)7 <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In C ptiance - No Violations <br /> 9_01 Other: § <br /> Comments 11 <br /> ��tri�v fy7f�C,¢,,:t�•o,• Ps.�Yn^ca.( a(Y�-'C!'��S-G{A`{i•-.—��SfcXt1 N�tXH�'s <br /> Inspection Form Included:Q x/.�/ } Z� <br /> Comments Included:Q X �3S Ksor� i�tr/y �109� `7��8-06 3. <br /> Business Rep�k Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK rCopyCl <br /> Incorrect: E X a Ah P L E 1 2 3 <br /> ■ Whit Yellow Copy Operator Pink Copy LEA ® ■ <br />