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07354040067 <br /> Waste Tire Survey & Inspection Report Inspection Report NumberState ■ <br /> CrWM 1181(Nmla Survey Form - Page 1 _ I_ 7 - 10 7 3 3 6 4 <br /> CIWMa 181(New nage <br /> Caelomla Integrated Waste Management Board - — <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- j rn Inspection Type (Fill one) <br /> Site Suffi=: t_I a S j (o i D _� - O_ �_ ®Routine Q Re-inspection Q Referral Q Observation <br /> Local / y/� If Referral,choose referral type(Fill one) <br /> Identifier. I '� _ --J Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name l/ Inspected By Inspector <br /> y� <br /> —T7 <br /> Ph ical Ad— s <br /> .?5�Ob1 <br /> �-/'- Inspection Date <br /> Time In_ Time a Out <br /> Business Rep Title 1 it !O AM I O AM <br /> /��►'I't'1 �,��L S �I'I V,'PYa'�iL l ti71� � i .. - - --'GPM � �' .. .i _ : O P M <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I I <br /> 0 0 ®Active ®Passenger ®Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude ®Hauler. ®Indoor <br /> O Q Inactive a Truck <br /> Longitude - Q Planned OT.F2 ®Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet ®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 l <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End=Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS O 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 O 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 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 O 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: § <br /> Comments I►�SS (S dale• Ifu l�A �t �V1( r1"Z "�'�115'POtrt to <br /> ­ <br /> is <br /> bQm 700 <br /> go9f, fid;, t=rMcl,CamP 7P/13135y1o51-01. C7ZS viwed,TSS 9� oh <br /> t2�o-s -✓ekz 1 e-S,–/�_r�i-s¢�/��rkl i H-S.No'�fi/►=e .,are 6r (� ht �a `mss �ci <br /> Fa �.QVI _ —Q�2 7 +1 6L�- /'Du�-1 ✓�p0'f$ -r "t1lQ ��✓i LQ . <br /> Inspection Form Included:Q ' /]pq <br /> Comments Ineiuded:Q—ztr—Y —�J W�•—y '�UW - �.,(4:�)a " �u/o l�� <br /> Business Rep's Signature Phone Number Inspect -S Si i ure Phone Number <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect:X(�% 9 11 EIIXI'AIIMIP I L I El <br /> 62081 <br /> ■ White Copy.CIWMB Yellow Copy Operator Pink Copy:LEA ® ■ <br />