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08184040087 <br /> in <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> $NVMR 181((Tia Survey Form - Pagel I 3 - 1 0 7 3_4. 5 1 <br /> CM1VMB 161(New OalW) <br /> "fomla Integrated Waste Management Board <br /> Part A-5urve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- El <br /> Inspection Type (Fill one) <br /> Site Suffix: �I 'I O 13 2 O Routine Q Re-inspection Q Referral Q Observation <br /> Local C �1 If Referral,choose referral type(Fill one) <br /> Identifier: C/R,i pgl ;�j C.OLM7 Q CHP Q CIWMB Q Complaint Q Educational Visit Q.Other <br /> Business or Facility Name /J Inspected By Inspector <br /> 7'ate 0 fA I�I <br /> Physical Address! 3 <br /> (_2�9 5 nl_a.oJ_I_e�2d I <br /> Street <br /> Inspection Date <br /> I- T� G.4 953 3� <br /> City Stale ZIP Code Time In Time Out <br /> Business Rep TitleI Q AM Q AM <br /> ��IDF�� --��� _..n.��'S_� /•_ --� .�O PM [�' QPM <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 /> f e T{p <br /> Active Passenger 0 Generator 0 Outdoor <br /> 10 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> i--._.__I•L _ ._ _.._—� Q Inactive Q Truck <br /> lQ End-Use Q Container <br /> Longitude Q Planned Q OTR <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 *Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use FacilityENFORCEMENT STATUS_ <br /> A HA LING AND ANIFEST REQUI E E T <br /> Q Notice Of Violation Q Extension <br /> Q Q I 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 for NOV or EXT) <br /> Q Q 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!C-IWMB 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 Other: § <br /> Comments <br /> -elE—tiVSP�-�1•/M/dY_7 %�so p�,�t�-� %� �lOst)r%✓9�.,1Ga.�N�;�EX:— <br /> _.�, U_.A--'�.►—lir►sl—/..L/�.£ wuea ic.d—/!/-��✓�',s�+^-`e�.fi'�t_ <br /> � - <br /> h'JGi�G!_�i-�s /�df.— <br /> Inspection Form Included:Q 20 <br /> Comments Included: — <br /> 9G <br /> k1usiness Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK eorre 1 i Incorrect X A M P LKUZ 3 62081 <br /> . White C py.Cl Yellow Copy Operator Pink Copy:LEA ® ■ <br />