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1 <br /> 03354040043 <br /> Waste Tire Survey & Inspection Report . Inspection Report Number <br /> $ratan 181(ar.i° Survey Form - Page 1 15 - 107 '13536 <br /> . <br /> rilWMe tat(New 11004) � <br /> ealgor; Integreted Waste Management Board -- <br /> Part A-SurveY BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 3 6 a ( S Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: CDS Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ((TT <br /> �Inspected By Inspector <br /> Physical Address 3 i1 t� � da goen.Nrh <br /> Inspection Date j Q Lal-vi <br /> rS4IXe+rV. GflTime In Time Out _ <br /> Business Rep Title I Q AM O AM <br /> •PM B PM <br /> �� 1+llttx 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 /> t (W Active Q Passenger ®Generator •Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude – Q Planned ®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 ®Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use FacilityENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q • Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 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 EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 114 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred f CIWMB Enforcement <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 114 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance'- No Violations <br /> Q 1 Q (Other: § — <br /> Comments <br /> o--7 <br /> —�u—r�/-'i—C_%,k—I?�•u�—Gl��r-e.ai� • G"/-LS—tei�.�cr/-sle/d»o <br /> Inspection Form Included-Q <br /> Comments Included:Q _ _ y(eP–oLe r <br /> Bus s i n Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> ■ INSTRUCTIONS ON BACK rect:� Incorrect: (� E X A M P L E111213 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy LEA ■ <br />