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« r. Waste Tire Survey & Inspection Report . Inspection p9gau0mbe2 <br /> rr stateof Calgomie <br /> VINNS 1181(New 04x14) Survey Form - Page 1 1 .6 - 1. 0 7 9 18 7 <br /> Cd{fomla Integrated waele Management Board <br /> Part A=Surve _ BLUE OR BLACK INK PEN <br /> (Business Profile Inspection Details <br /> TPID- Inspection 3 ? - O I Inspection Type (Fill one) <br /> Site Suffix: J J 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local SQrI f0 A U 1n Gcx l If Referral,choose referral type(Fill one) <br /> Identifier: 9 �{ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or facility Name Inspected By Inspector <br /> PhyRIodI�Add eSSTra�sPoSl-atiorf <br /> y 3 `� 1 0 1 LKcist�ctr Lu_c_as� <br /> �3G33 Duck Gceek pr i <br /> Street FoN <br /> Inspection DateZ Q / FOT8_1 <br /> L—S4o.c kL<w CA QSZ � <br /> city State 4 ode Time In Time Out <br /> Business Rep Title m'm O M m'F O PM <br /> —�ahf1 L tfto J1_SeC-J1-CQ—MMctt�d ¢r _ — — -------- <br /> -- 9 Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) + T (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active Q Passenger 0 Generator •Outdoor <br /> D Q Closed Q Altered <br /> GPS Latitude I I I_ Q Hauler Q Indoor <br /> LmJ Q Q Inactive 40 Truck <br /> Longitude - <br /> I, Q Planned Q OTR Q End-Use Q.Container <br /> Business Type (Fill all that apJply) JJ <br /> Q New Tire Dealer Q Auto Repair •Trucking Fleet Q Government Q Relreader 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 I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V , 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date 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 i 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 f CIWMB Enforcement <br /> Q 000 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 Q Other: § <br /> Comments !a <br /> _1 <br /> Ra��fifu, iYlsoeGt►Q�,P.et�ot�_-�4i►5_—dn-�e.--��I�e__.o_1.1ok..>►� s <br /> rv�e ntYes�s he�[e beer rzka�l necl k,)eCe—a�[oa\-abbeac Y3.V_1 ew_v,. <br /> Inspection Form Included:Q (zo <br /> Comments Included:Q <br /> iness Re 's SI nature Phone Number In or's Signatur_ Phone Number <br /> INSTRUCTIONS ON BACK Corr t: Incorrect: I X A M P )r c 1 Z 3 62081 <br /> ■ - White opy:CIWM Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> i• <br />