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0812941113 <br /> " Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> C]WM f181(N. Survey Form -Page 1 1 4 - 1 0 7 2 8 2 6 <br /> CIWN81tt(New ONedl <br /> CaIl U"ia Intagrat*d Wact*Manag*mmt Board <br /> Part A-Surve _ BLUE OR BLACK INK PEN <br /> Business Profile l Inspection Details <br /> TPID- ( l 3Ty a�o I O Inspection-Type (Fill one) <br /> Site Suffix: I I q 4 / I$Routine Q Re-inspection Q Referral Q Observation <br /> Local �r _ /� If Referral,choose referral type(Fill one) <br /> Identifier: Com` l J tl.�'(�� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> /W.5PA-d—re—ss <br /> ysica3 1 L V v'�' LS✓_—J <br /> 20 iso r- tQa ac� #a3 <br /> Street / D / <br /> �� / Inspection Date <br /> dy Stale ZIP Code Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> �- c - M 0 PM LLI 0 PM <br /> Operational Status Tire TypeBusiness Role Storage Type <br /> Tire Count(Whole/PTE) ; /� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> t V ®Active ®Passenger ®Generator Q Outdoor <br /> I- I <br /> ID Q Closed ®Altered <br /> GPS Latitude I Q Hauler Q Indoor <br /> Q Inactive ®Truck <br /> r � i 0 <br /> Longitude — I I I I F Q Planned Q OTR Q End-Use ®Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ®Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire De ved 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 le Other I TI-ewsFc,,- 5bPt'c'?,1 <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORC-EMENT STATUS_ _ <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q Q Notice Of Violation Q Extensio <br /> 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 i Q PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Dat / LU <br /> / <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 equired for NOV o EX77 <br /> Q IQ 14 CCR§18459.3-Relention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Referred PIN-FAB 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 C-ompliance - No Violations <br /> Q Q Other: § <br /> Comments 01 onj l dGtbatg� I_V/Ib <br /> ad duG -P( GAS �0 ruyi at/�fLl� r 6_ & -t its . OT�, <br /> Vd 17__d �i Yf�n�o vecQ. N o k _ <br /> &h_As,, <br /> Inspection Form Included:Q J <br /> Comments Included:Q oc Sign <br /> Business Rep's Signature Phone Number Insp c or s Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK jEjXjAjMjPjLjEj 111.2131 <br /> ■ White Copy.CIW MB Yellow Copy Operator Pink Copy LEA ® ■ <br />