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08157040018 <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> rr State of.11-6 <br /> R CIWM5181(N..0"4) Survey Form - Page 1 1 6 1 0 7 9 2 0 4 <br /> Celilomia Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection IC F1 / / - D / Inspection Type (Fill one) -- <br /> site suffix: L J V `� I t0 Q Routine Q Re-inspection Q Referral Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: .��^( �T Q�„� N,y 0C <br /> _ , <br /> HP - Q CIWMB Q Complaint Q Educational Visit Q Other - <br /> Business or Facility Name (� +� Inspected By Inspector <br /> Physical Address L?Stre �`, <br /> Inspection Dale 7 <br /> L_6 State ZIP Code Time In Time Out <br /> 1 FTI <br /> Business Rep Title El Q AM Q AM <br /> •[ O PM I O PM <br /> - - - - - J Operational Status Tire Type Business Role Storage Type <br /> Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire � 5, `� <br /> 1 / 0 Active Q Passenger 0 Generator O Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> - - 1- _ Q Inactive 0 Truck <br /> ` I ILongitude -� Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) — <br /> Q New Tire Dealer p Auto Repair 0 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 I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V j A HAULING AND MANIFEST REQUIREMENTS <br /> O Q Q Notice Of Violation Q Extension <br /> PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O 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 IXT) <br /> Q 0 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/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 1 Q 1 Other: § m /� / / <br /> Comments __v � aY1 J2/SV�G .C—�D/-�61.�1_u _WGI.,S <br /> ��� CY�(R�,�ee.�1fG L4_C.G_►2c�_4.54.3-Q� �, e-F �r-L.s—��_yc�rs. <br /> Inspection Form Included:Q — CZd <br /> gni. 1_ _a �GaB_46 <br /> Comments Included:Q— — <br /> Business R p' nature Phone Number Inspector's Signature Phone Number_ <br /> INSTRUCTIONS ON BACK orrect. Incorrect: 1 X A M P L E 1 2 3 62081 <br /> ' <br /> . White y CIW Yellow Copy.Operator Pink Copy.LEA ® ■ <br />