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07354040044 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> CIWM ■ <br /> stataeB B1(New'181(New 04!04) Survey Form - Page 1 18 - 1 0_7 3 5 3 9 <br /> "Ifomla Integrated Waste Management Board <br /> Part A-Survey _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 3 7Z 3 S y-7 ; y d ' a Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: C Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Wats- P - -i- - -- <br /> Physical Address : 3 <br /> W 13 MofFFo:t 131VA. - - -— - <br /> Inspection Date <br /> X75 33 <br /> �u.N�<C� CIA Time In Time Out _ <br /> Business Rep Title O AM Q AM <br /> G S PM ®PM <br /> �� a�►1a v� -- �"�tu � rh' Operational Status Tire Type Business Role Storage Type <br /> Tire Count(W holelPTE) (Fill one only) (Fill all that apply) (Fill all that apply), (Fill all that apply) <br /> ' ° a le Active Q Passenger 0 Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor . <br /> O Q Inactive Q Truck <br /> Longitude _ Q Planned ®OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q 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 ®Other ��d <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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / 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 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 0 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 Compliance - No Violations <br /> Q Q 1 Other: § <br /> Comments <br /> - -ct,c�wta. _,.,.�Sy.—Gtr-�•�'u�.�a�i•' ��-�—��-��—�,�orPYitcS-. _ <br /> T"yts—�?yx4.n�ed �.p�� 3—y�.,oitaK_.c.—�nkn/,Ll�.c �'LG✓�71ar,—� uud r..a-�- - <br /> ��1Lyr�T— J�?��.�-�f frua�lfr_;c.�o�sc.w_rd�� f•'��i.t;e.�Scw,.4�c(-!� <br /> Inspection Form Included:Q <br /> An C a <br /> Comments Included:Q x �—L —O 0 _ L� 6__3 <br /> Business Rep's Signature Phone Number nspeetor s Signature Phone Number <br /> _ - �,( - - — 62081 <br /> INSTRUCTIONS ON BACK Correct:* incorrect: (� NJ X R IM P L E 1! Z 3 <br /> ■ White Copy CIWMB Yellow Copy.Operator Pink Copy.LEA ® ■ <br />