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073S404004S <br /> ■ <br /> im <br /> Waste Tire Survey & Inspection Report . Inspection-ReportNumber <br /> ClWM181( ew i SurveyForm - Page1 ( 7 - 1 073538 <br /> CNVMe 181 New nage California Integrated Waste Management Board . - - <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile_ Inspection Details <br /> TPID- Inspection/ O , Inspection Type (Fill one) <br /> Site Suffix: I '�17 3 % . 7 •Routine Q Re-inspection Q Referral Q Observation <br /> 'Local I I If Referral,choose referral type(Fill one) <br /> Identifier: _ y�, Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> r— <br /> �Ori C) <br /> Physical Address n <br /> _ l}.S 3 3 S• Carr,covL�Sc P,rpt . -- -- -- <br /> Inspection Date i Q - . / <br /> C I I�- <br /> Mcwt K cw A J 3 3 L - 1-- <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> ;OPMOPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active 40 Passenger ®Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q 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 Is Other ��s <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A I 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 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 E>M <br /> Q 014 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 /> 010 1 Other: § <br /> Comments <br /> �trtuhi�c—�.r_rs�te.c�+o_t�_d.._�cS_dmta.�.-6wr.�r_c�,,_�.�c'-P-P='f�c..• -��.1'cL"'�� <br /> -(_l�.w�-Pts w;-II I,� 9 . 0 yrs—'�i.t�S—l�•t—�+tut.Q.tc�-.��kau-In_r,r�e{�=oto-c-r-{c I <br /> Inspection Form Included:Q v <br /> /� C�/li(/'f yG S-067,3 <br /> Comments Included:Q <br /> Business Rep's Signature Phone Number nspector s Signature' Phone Number <br /> jp� 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect:X� X A M P L E 1 2 3 <br /> ■ While Copy CIWMB Yellow Copy Operator Pink Copy.LEA ® ■ <br /> I <br />