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Waste Tire Survey & Inspection Report Inspection Report NumberStale ■ <br /> crwmf181 JNmIB Survey Form - Page 1 t - 0 Q 7 <br /> CIYVM8181(NeW OU04) <br /> CallEomla Integrated Mate Management Board <br /> Part A-Survey _ _ BLUE OR R BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection t Inspection Type (Fill one) <br /> site$Uffix: <br /> f1� © ®Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local (� If Referral,choose referral type(Fill one) <br /> Identifier: �t�. I Q 0 CHP 0 CIWMB I)Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name i <br /> \ Inspected By Inspector <br /> Physical Address <br /> ( 1 SSI <br /> Sfreef <br /> Inspection Date /t1 f I Es <br /> 1Q1 <br /> / o W <br /> t'y ate Zip Code Time In (� Time Out <br /> Business Rep j Title m [= := <br /> "4r ce 0P <br /> O PM <br /> _ Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all(hat apply) (Fill all that apply) (Fill all that apply) <br /> ®Active 0 Passenger 0 Generator 0 Outdoor <br /> 1 <br /> Latitude 0 Closed 0 Altered <br /> GPS 0 Inactive 0 Truck <br /> �. 0 Hauler 0 Indoor <br /> Longitude ` I (0 <br /> g '• I i I I I 0 Planned ®OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) -— <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder Other <br /> tip►" �t I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility E FORCE_MENT STATUS <br /> V I A I HAULING AND MANIFEST REQUIREMENTS <br /> PRC 42951-Waste Tire Hauler R 0 Notice Of Violation 0 Extension <br /> 0 0 § Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 0 PRC§42956-Registration/Decal in Vehicle Compliance Deadline <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date EI / M / [E <br /> 0 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EX>) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years `---- <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred I CIWM8 Enforcement <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators T <br /> § in Compliance - No Violations <br /> 1010 Other: <br /> Comments /Ks S <br /> �a'r-�� - '�- �- <br /> L�r�,(rJi�CQS -f'✓'r�c:�tJ�.S •8—�1.�� —��.1t�r4lti __ �,�L�bfhL� _l_t�_�CJ_ <br /> --t V�uC�es S. <br /> ri+Q tiYeS <br /> i� <br /> 7.- <br /> Inspection Form Included:® A "t'�� <br /> Comments Included: ( ;� C�t�(1XJY_' <br /> _ Business Rep's Signature Phone Number Ins tors nature Phone Number <br /> ■ INSTRUCTIONS ON BACK Correct: Incorrect: (6t) E I X1 AIMAIMI P I L IE Z 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br />