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08129041100 <br /> Waste.Tire Survey & Inspection ReportInspection Report Number <br /> Sul CrWM 191(New Survey Form - Page 1 1 9 10 7 2 8 3 9 <br /> CNVMB W (New..g <br /> Call}Omla Integrated Waste Management Board� Y � .—� <br /> Part A-S. <br /> BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- (/ LO <br /> / Inspection Type (Fill one) <br /> Site Suffix: :tI�L Il_3 (� 7 Ia Routine Q Re-inspection Q Referral Q Observation <br /> LocalI�p 'rf If Referral,choose referral type(Fill one) <br /> Identifier. �-�`" v J 00 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Buslness or FacilityName V _ Inspected By Inspector <br /> Physical Address j�' ,�� � ��t I <br /> I l U U -—PU/y-.yy )Street <br /> 95330 <br /> Inspection Date <br /> Lok <br /> h � / <br /> City State O O o R <br /> ZIP Code Time In Time Out v <br /> Business Rep Title m FT] <br /> Q AM Q AM <br /> L : FT1 <br /> ��� QPM - QPM <br /> W`�r`. - ----- -- - <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) D (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> ' } ®Active O Passenger ®Generator O Outdoor <br /> /� <br /> O O Closed 0 Altered /�1 <br /> GPS Latitude I I IO Hauler Q indoor <br /> _ O inactive ®Truck <br /> Longitude - ' I 0 O Planned Q OTR O End-Use Q Container <br /> iFTT <br /> III <br /> Business Type (Fill all that apply) <br /> I <br /> O New Tire Dealer O Auto Repair ®Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder le Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility N ORC-EME T ST 5 <br /> V ULING AND MANIFEST REQUIREMENT otice Of Violation Q xtension <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. ompliance Deadline <br /> O o PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <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 (Required(or NOV or EX <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!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 mpltance - No Violations <br /> 10 1 <br /> Q1 Other: § .A } <br /> Comments pf� 1r p -n S�/e <br /> ep <br /> � (/ oO/U tks�s _TJu j 71�-e h,- De-fi+e__ Ui Cie- as /-Rj <br /> o IMQ�e_S+ rn > C� VeAldo, ,Seta <br /> ifs_- -Am o(- less _/'_e n OW 3 <br /> Inspection Form Included:O _ <br /> Comments Included:0 "�" -`�•�/ <br /> Busin s Ws Signature Phone Number Inspector Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: M X A P .L E; 111,2131 62081 <br /> ■ White Copy CIWMB Yellow Copy:Operator Pink Copy LEA ® ■ <br />