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oso�oogois© <br /> r <br /> Waste Tire Survey & Inspection Report Inspection Report Number- <br /> State olCd(New Su-rVe Form - Page 1 1 2 - 1 Q 7 3 3 7 6 <br /> c"me tst(New oval �/ <br /> Gleamis Intagratad Wasto Managamant Board l <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details ' <br /> TPID- ( Inspection Type (Fill one) <br /> Site Suffix: 1 g g O ®Routine O Re-inspection O Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: L�_M Q c O CHP O CIWMB O Complaint O Educational Visit O Other <br /> i <br /> Business or Facility Name - — <br /> N <br /> rs Inspected By Inspector <br /> AaA <br /> PhysicaT Address— <br /> q30 E Owt&t 00a <br /> Street D <br /> ' 9s ani I Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep/� Title O AM O AM <br /> ..O <br /> 1 s:e—IjO.Cd-�V_A L— 2GR iu C�C—P, m m O PM m'm O PM <br /> Operational Status Tire Type Business•Role Storage Type <br /> I (Fill me only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) I l <br /> ®Active ®Passenger ®Generator - ®Outdoor. <br /> L�� O O Closed O Altered <br /> GPS Latitude J � 0 Hauler Q Indoor <br /> O Inactive O Truck <br /> Longitude - O Planned O OTR O End-Use O Container <br /> Business Type (Fill all that apply) <br /> O New'Tire Dealer O Auto Repair O Trucking Fleet O Government O Retreader ®Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture O Shredder O Other I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> WJFIWU1111NG A U MANIFEST E(]UI EMENTS O Notice Of Violation O Extension <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§16459 -Responsible Entities Complying with Manifesting Requirements <br /> O O 14 CCR§16459.1-Tire Program ID Number from CIWMB <br /> O O 14 CCR§16459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Requved for NOV or EXl/ <br /> O O <br /> 14 CCR§16459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred t CIWMB 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 ®In Compliance - No Violations <br /> O O Other: § <br /> Comments (�pr�C 4" f fr12 l lil�CLj �j}fid.' <br /> `tGu-�- r�lctSf� *e-S If C rusApd <br /> D 4. rip rD ratwt t�isc.�s�e2( ,_� <br /> Inspection Form Included:O ' <br /> Comments Included:O >n.t.Nr �Business Rep's.Signature Phone Number g ure Phone Numbe <br /> INSTRUCTIONS ON BACK Correct. I co eet: X A M P E1 1][2131 62081 <br /> ■ White Copy.CIWMB Yellow Copy:Operator Pink Copy.LFA ® ■ <br />