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OS�52�40760 <br /> see. <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State o181(omla SurveyForm Page 1 1 1 - 10 10 8 4 0 <br /> CIWMB 181(New 04104) � ('� <br /> Ca=rated Waste Management Board "�' <br /> Part A.Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: / o? q 71 0 7:H 40 Routine Q Re-inspection Q Referral Q Observation <br /> Local (� � If Referral,choose referral type(Fill one) <br /> Identifier: LJ�,� � Q CHP Q CIWMB Q Complaint . <br /> Q Educational Visit .Q Other <br /> Business or Facility.Name <br /> - IlInspected By Inspector <br /> 1 X -;-;L <br /> _ D / 41 <br /> Physical Address X1 <br /> I <br /> 1. 735-f-' . 7/;141 <br /> Street <br /> a fs�;olJ Inspection Date <br /> CityuCe/a State ZIP Code Time In Time Out <br /> Business Rep Title O AM <br /> OAM <br /> LLI0 PM H] 0 PM <br /> _ _ _ Operational Status Tire Type Business Role Storage Type <br /> vl I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(WholelPTE)I I <br /> t I. ° _- /_ a Active Q Passenger •Generator ®Outdoor <br /> r O Q Closed Q Altered <br /> GPS Latitude L�. Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude — � i I Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair i 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 <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST RE-QUIREMENTS 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. C-ompliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / IE / 11:1 <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire 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 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In C-ompliance - No Violations <br /> Q Q Other: §§ <br /> Comments /lei-�y/�[���t2. i~ .� `�i...f Q/ ��GQ /l �v� �llq�✓/��ca�I'�{q� ,. � <br /> -�"'�/c�-,.-7`r - ��'° X7'1/'� � -�-•,r- moi'/L 'n. �a�.��tj�' ��y <br /> e/L `r vi°�r�a✓ n <br /> Inspection Form Included:Q 20 <br /> Comments Included:Q.— <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: In�orrect: EXAMPLE�3 62081 <br /> ■ White Copy.CIWMB Yellow Copy.Operator Pink Copy.LEA ® ■ <br />