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, 09196U40490 <br /> Inspection Report Number <br /> Waste Tire Survey & •Inspection Report <br /> State B Call(New Survey Form - Pagel I 1 - 1088070 <br /> CIWMB 181(New 04104) Y <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � {� � t� � � � Inspection Type (Fill one) <br /> Site Suffix: j 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local Sun J o U1 If Referral,choose referral type(Fill one) <br /> Identifier: r\ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name ,, \\ Inspected By Inspector <br /> Al <br /> Physical Address 1 V , L& <br /> J)Sslt CkM A�xk�kInspection Date_— —-O Time In _ Time Out �l <br /> City State !P Coe ___ <br /> Business Rep Title I { -�Q AM I S1 OAM <br /> I <br /> aF_V - X 6th} - CSW nV El X <br /> . Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that•apply) (Fill all that apply) (Fill all that apply) <br /> ®Active 0 Passenger 0 Generator to Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive A Truck <br /> Longitude 0 Planned OTR 0 End-Use 0 Container <br /> I <br /> Business Type (Fill all that apply) f <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber L <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other f m— <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility MENEeRBEIVIENT S1TA7US <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice iolation <br /> Of V0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date mM <br /> / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days .(Required for NOV or EX77 <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators �In Compliance - No Violations <br /> 0 1 0 1Other: § <br /> Comments -- <br /> Abfa_- <br /> NJ <br /> Inspection Form Included: 0 <br /> Comments Included: i 7 i -�— <br /> ass Rep's (gnat a Phone Number Inspe ors Signature Phone Number <br /> INSTRUCTIONS ON BACK C r �lnorrect: 62081 <br /> c <br /> EXAMP :LE. 1Z3 <br /> White C py.CIW B Yellow Copy:Operator Pink Copy.-LEA <br />