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Waste Tire Survey & Inspection Report Inspection epo umberstat"of ■ <br /> cfWMB18114 la Survey Form - Page 1 1 8 - 10 7 9 10 7 <br /> CIWMB 181(Now 01lW) <br /> Call/omla Integrated Waste Management 9oard <br /> Part-A-Su BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- i[K�] <br /> - O Inspection Type.(Fill one) <br /> Site Suffix: F <br /> Lk 0 Routine O Re-inspection O Referral Q Observation <br /> Local H Referral,choose referral type(Fill one) <br /> Identifier: I San -j-o aqu►n CQlU1�y O CHP O CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> �—T_T <br /> Physical Address - <br /> LK_rist'i4n L.ucas� <br /> Street <br /> y/y� Inspection Date <br /> I ���` C 9'5- "O� Time In J Time Out <br /> City State ZIP Cooe <br /> Business Rep Title C O AM T1O AM <br /> T1Qfiimaq of m'ED O PM O PM <br /> ck�)CL <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) 6J 2 <br /> I •Active O Passenger •Generator •Outdoor <br /> O Closed O Altered <br /> G PS Latitude I- _ O O Inactive 0 Truck O Hauler <br /> Indoo <br /> Longitude O Planned O OTR O End-Use O Container nerf0� I � <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repair 0 Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler. O Agriculture O Shredder O Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires O Notice Of Violation O Extension <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O O 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or F,(1] <br /> OO — -- - <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred 1 CIWMB .Enforcement <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance'•- No Violations <br /> O O Other: § <br /> Comments <br /> Rou�lne. 'ti�ns_ps.ct'►s�r_�—Pe'C�o[vLted -t4,�s L�Q-� � flu. n!_Low_i�t,a_4s a.afq�: <br /> filo v►o\At�ons oc_nr_eoS oconcer_ern-ekedZ�iS �ca.lt �scS-Q�7ixe_ <br /> a� ui_aSke tine laou\ia�SCEo7s _eA.'%neA_A a+w.A ble <br /> olc LQS >e-C-, �' _CL <br /> Inspection Form Included:O Coal r `Zd� <br /> Comments Included:O <br /> Business Rep's ignature Phone Number !tors Signatur _ Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK r c : Incorrect: ]( X A M P L E! 2 3 <br /> ■ - White Copy IW M Yellow Copy Operator Pink Copy.LEA ® ■ <br />