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OEQia0401EE <br /> Waste Tire Survey & Inspection Report Inspection Report NumberStat ■ <br /> CrNMR181of (Nrnt° SurVe Form Pa e.1 1 2 . 10 7 3 5 9 0 <br /> CIWMB tgf(New nage y. <br /> Callfomia Integrated Waste Management BOeW <br /> Part A-Surve BLUE OR BLACK INK-PEN' <br /> Business Profile Inspection Details <br /> TPID- Inspection C 3 y Z Inspection Type (Fill one) <br /> Site Suffix: J [Toll <br /> O Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �tyl c� ,r Q CHP Q CIWMB Q Complaint Q Educational.Visil Q Other <br /> Business or Facility Name'' <br /> Inspected By Inspector <br /> Physical Address 3 - mo / <br /> ��fr""•" <br /> 2°I 0 9 9t7 ecu t0 �oA <br /> Street <br /> Inspection Date <br /> ity State IP� Time In Time Out <br /> Business Rep Title m' <br /> F I l®PM m'm ®PM <br /> t �tC-�etc.� �lnflrtC'� Y t'�`�ocw.ar` <br /> Operational Status Tire Type Business Role Storage Type <br /> 1 I i (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE)' 1 <br /> ° I I °• I 1 1 ®Active .0 Passenger ®Generator ®Outdoor <br /> (( O Q Closed Q Altered <br /> GPS Latitude �,L-� Q Hauler Q Indoor <br /> L <br /> Ir�I� 0 Inactive Q Truck <br /> L <br /> Longitude - � I I IO Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) JJJ��� —J�J <br /> Q New Tire Dealer Q Auto Repair a 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 <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility _ENFORC-EMENTT STATUS <br /> NMI 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 <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/or NOV or EXT) <br /> Q O <br /> 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 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In 676pliance No Violations <br /> Q 1 Q 1 Other: § <br /> Comments - <br /> ,�t.kr�to. _j "�'z — <br /> LZrt_ �rir hiss—Liars I�ar>ri✓re/T nw�`� <br /> Alpw alarf Vis,—�� F, <br /> Inspection Form Included:Q <br /> Comments Included:Q <br /> Business Rep's Signa ure Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Co rect:� Incorrect: E X A M P.L E' 1112131 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA ® ■ -� <br />