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08129041109 <br /> c Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> SlatMS18llt­ni(Now survey Form - Page 1 1 3 1 0 7 2 8 2 <br /> CNVMe 1B1(Now 04/04) <br /> col U-; Integrated wase Management Board _ <br /> Part A-5urve _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- U Inspection Type (Fill one) <br /> Site Suffix: �/ 1 L�i <br /> U� " ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ��Q `J'LJ /l//� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name k <br /> Inspected By Inspector <br /> r,.o_V <br /> Physical Address <br /> L_Af l o m on t 1_�'. <br /> Street r-i <br /> [-0] / <br /> n,r 95�� I Inspection Date fl <br /> dy C`J l�ilF/^T/�1 /l/S'4 y / tater Tlme In Time Out U <br /> BMsiness RLep T�it�ley� O AMM LI] <br /> O AM <br /> in <br /> -- -- ---- ✓✓✓_-- Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> -- I <br /> GPS Latitude I_—__J.I 1 — I I O Q Closed Q Altered Q Hauler Q Indoor <br /> � O ®Inactive Q Truck <br /> Longitude tI j 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 Q Car Dealer Q Collection Q Crumb Rubber � <br /> L—�c�r r 4z l <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ®Other rr�J <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFO_RCEM_ENT_STAT_US_ _ <br /> V j 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 Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / 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 (Required for NOV or EXT) <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/CIWMB 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 Compliance - No Violations <br /> Q Q1 Other: § <br /> Comments ° n <br /> _ <br /> �,�.lafy_ _yes HP� {�Dr ✓'Q�laCir� �rk1Li.Ff�-i}''2 C7Ls ✓i eu✓f�- <br /> ti 3 Vo l kwi e__. -ti res v <br /> Inspection Forth Included:QI <br /> Comments Included:Q�_ D � ci— <br /> Business Rep's Signa Phone Number Inspector Signature . Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: (� X A M P L E 1112131 <br /> ■ White Copy.CIWMB Yellow Copy Operator Pink Copy:LEA ® ■ <br /> I <br />