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08129041111 <br /> Waste Tire .Survey & Inspection Report .Inspection Report Number <br /> Stats of CaMomis Survey Form - Page 1 1 5 - 10 7 9 15 3 <br /> clwMe 1e1 IN.Y.ouoq �/ <br /> Cslllemla IMagratatl Wash Managamanl Boani 7 <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile 7� 77 Inspection Details <br /> TPID- I �I, O Inspection Type (Fill one) <br /> Suffix: (0 <br /> Site SI ®Routine Q Reinspection Q Referral 0 Observation. <br /> Local If Referral,choose referral type(Fill one) <br /> IdentHier. so <br /> Q <br /> Bsiness or Facility Name Q CHP Q CIWMB Q Complaint Q Educational visit..0 Other <br /> Rpm <br /> Inspected By, Inspector <br /> Iu <br /> ae <br /> Physical Address I [3R] - <br /> �01 a/l,�wc - -- <br /> I .l I <br /> O <br /> /������ <br /> Street Inspection lite <br /> city � VI tate zip code Time In Time Out <br /> Business Rep Title O AM Q AM <br /> Q PM 'm O PM <br /> Tear _ _$l a"aAh - -- -;rvm�_ r' <br /> Operational Status Tire Type Business Rote Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fin all that apply) (Fill all that apply) <br /> I I ; ('� j I <br /> (a Active Q Passenger ®Generator O Outdoor <br /> I O Q Closed p Altered <br /> GPS Latitude I • I_�� I Q Hauler ®indoor <br /> --A L_ <br /> I(_ TT-1 <br /> O Q Inactive ®Truck <br /> Longitude - I 1 0 Planned Q OTR 0 End-Use Q Container <br /> _ I <br /> Business Type (Fill all that apply) _ <br /> O New Tire Dealer Q Auto Repair ®Trucking Fleet Q Government Q Retreader Q Dismantler 0 Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body Q Car Dealer O Collection O Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture O Shredder O Other L I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A M I $ Q Notice Of Violation Extension <br /> 0 O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance cad ine <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§16459 -Responsible Entities Complying with Manifesting Requirements Date <br /> O O 14 CCR§16459.1-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Req vied for NOV or EXT <br /> O 0 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 Refer ed/C^IWMB 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 ®I CornpIian aM141131 BVI.lal1010 1 atio <br /> Other. §, 1_}- / �,/ <br /> Comments �pr,,-�,„„� l� uA dtat i no f-F�( -t o 1 j �Q o <br /> ovl sr a}- �ix�e �F IVLS c e-0 . /U o viol`MIS <br /> Inspection Form Included:Q 1 <br /> Comments Included:Q <br /> Busy es ep's Signature Phone Number Inspect s'Signaturo Phone Number <br /> INSTRUCTIONS ON BACK or„act:_ NEVA M 1PILIE1 11W3 62081 <br /> ■ White Copy.CIWMB Yellow Copy.Operator Pink Copy.LFA ® ■ <br />