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. 080380403.14 <br /> "" Waste Tire Survey & Inspection Report . 'Inspection Report Number � <br /> SlabBIBIlernlx Survey Form - Page 1 13 - 1 1 0 8 3 4 <br /> CM'MB 187(New 01/01) <br /> California Inlegraled Waete Management 9eard _ <br /> Part A-5urvey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- j Inspection Type (Fill one) <br /> Site Suffix: I Y j / ®Routine Q Re-inspection Q Referral Q Observation <br /> Local. n / If Referral,choose referral type(Fill one) <br /> Iden lfier: C//fig Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address lW-,-9, <br /> I _n$9 7 ��i '� f 1 <br /> Street <br /> Inspection Date <br /> City ^' State ZIP Code Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM ------— O PM <br /> _ T Operational Status Tire Type _Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> r r (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I�L . <br /> � i <br /> —_ ®Active Q Passenger ,Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude _ Q Hauler Q Indoor <br /> C Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer ®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 /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other I 1 <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENORC-EMENit STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q Q Notice Of Violation e <br /> PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance l�adlin <br /> Q Q PRC§.42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Re.ured for NOV or EXT) <br /> Q Q 14 CCR§18459.3-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 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 C-o pliance - o Violations <br /> Q 1 Q Other: § 1 <br /> Comments �4.eL, G�C7 .�L.�� �t�..a✓,p u/Qa1f'� C/��'y -,7 <br /> Inspection Form Included:Q; <br /> Comments Included:Q..�,e.��,� / <br /> I Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK E XAh R P LjEj 11[2131 <br /> 62081 <br /> ■ White Copy CIWMB Yellow Copy:operator Pink Copy LEA S <br />