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Waste Tire Survey & Inspection Report inspection Report Number <br /> swedc.I". Survey Form - Page 1 ( 3 - 1 01 3 0 4 4 <br /> crvwa rar N.w oaros) <br /> amar,�.Musrrww.se.M,..y.+�.mao.a BLUE ORB e - K EN <br /> Part -Surve _ <br /> Business Profile Inspection Details +�V <br /> TPID- Inspection <br /> :020] O� Inspection Type (Fill one) <br /> Q ObservationSRa Suffix: ! lf! ®Routine Q Re inspection Q Referral <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �a� T� (�( Q CHP Q CIWMB-Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V `J`�j Inspected By Inspector <br /> `(_5,:,�rs <br /> Physical Address <br /> 00 o <br /> rt oef , Inspection Date r O a D <br /> s-�b�k�pn �'}I �5a0(� Time out <br /> City Marc ZI Code , Time In T 111Business Rep Title �Cjj 1 ' {OPM fO AMOhS L -IL-Jf �I• O PM <br /> _h�� ��' - � 0 ==--+i Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) <br /> (Fill alt that appM (Fill all fhat apply) (Fill all that apply), <br /> Tire Count(Whole[PTE) i1 <br /> ®Active ICPassenger 100 Generator Q Outdoor <br /> I� p Q Closed I Q Altered j <br /> GPS Latitude _ Q Hauler Q Indoor <br /> - - - Q inactive o Truck <br /> O <br /> Longitude - j Q Planned a OTR <br /> Q End-Use Q Container <br /> Business Type (Fill all that apply) — <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet p Government Q Retreader Q Dismantler p 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 0 Other Me7"a.� <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V i A ,HAULING AND MANIFEST REQUIREMENTS 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 PRC§42956-Registration/Decal in Vehicle <br /> IQ I Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Det.M/m/ M <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> f (Required for NOV or F_XT) <br /> �Q <br /> 10 14 CCR§18459.2.1-Submittal of Manifest Fortes and Tire Trip Logs within 90 days - - <br /> Q-Q 14 CCR§16459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred I CIWMB Enforcement <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities -- <br /> Q ® 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators I •In Compliance - No Violations <br /> Q Q Other. § - <br /> --— -- <br /> Comments g lJl.4. fhS�Q tD �(rvrs�TO ISI ct 71pt20 �1$LY► - <br /> ,(¢ 5�erv'.ces�t, - <br /> v�aeJ EDT_ ay _ a�il2 �+Kh, C�►a ceR ig�traesS- <br /> Ras_o_F_ s} bTs_aI_ <br /> Inspection Form Included:Q� �- <br /> C 14 N�amments Included: s esPhone Number Ina J s Slgn t re Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: (� l�J E X R Ati P L E1112131 ® ■ <br /> White Copy CIWMB Yeiiow Copy Operator Pink Copy LEA <br />