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08255040021 <br /> L Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> at."Sof 161"�� Survey Form - Page 1 i 8 1 0 10863 <br /> CIWMB 161 IN•w nage Y <br /> c.ero�,i•mtseraarl waste wn•g•m•m eo.rd <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection_ O / Inspection Type (Fill one) <br /> Site Suffix: O J / 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local / H Referral,choose referral type(Fill one) <br /> Identifier: �. �N Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> /� � Inspected By Inspector <br /> Physical <br /> Street Inspection Date <br /> I 71 <br /> City State Zlp Code Time In Time Out <br /> Business Rep Title 0 AM EE] Q AM. - <br /> �! <br /> 46,-,4' I mo( m FF] <br /> O PM O PM <br /> - _ <br /> (Whole/PTE) <br /> WholelPTE' Operational Status Tire Type` Business Role Storage Type <br /> Tire Count <br /> � r i (Fill one only) (Fill all that apply) (Fillill <br /> all that apply) (Fill all That apply) <br /> 0 Active 40 Passenger 0 Generator *Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude m• Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> llll <br /> Longitude - �. Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> •New Tire Dealer i 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 L I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility EN ORQ EMENMIS;fTATLUI& <br /> V A S EQ E EN <br /> 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 <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV r F>C� <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 Referred I C-1WMB 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 1 Q 1 Other: §• <br /> Comments -).Q <br /> 2r 4PPg S %.l�aj�o 'S. <br /> V 'n! <br /> Inspection Form Included:Q <br /> Comments Included:Q- <br /> s re nese s SignatuPhone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK C• e t 1 jEjXjAjMjPjLjEj_ j1t2131 62081 <br /> ■ White Copy CIWMB Yellow Copy Operator Pink Copy:LFA ® ■ <br />