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osissoq©sss <br /> Waste Tire Survey $ Inspection Report Inspection Report Number ■ <br /> CtNMB 181(N w Survey Form - Page 1 1 4 - 1 0 7 2 8 5 9 <br /> CNVMB 181(New 04lgd) <br /> call/amts Integrated Waste Management Board <br /> Part A-Sze BLUE OR BLACK INK PEN <br /> Business Profile f Inspection Details <br /> { TPID- / /� Inspection Type (Fill one) <br /> Site Sutfix:. / 13 18 I L V D <br /> Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �ja J J pqg c�r-� � 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name T <br /> ^� Inspected By Inspector <br /> [� 9] _ / O / <br /> Physical Address I�1 �E� <br /> /820 Ac_AA77,t.CQ �� I <br /> Street <br /> Inspection Date <br /> City / —Slat esZ P C�odee Time In Time Out <br /> Business Rep TitleO AM O AM <br /> ' QPM QPM <br /> Leo�r g les% l �Gf,�,rF,t,,�C <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) / O (Fill one only) (Fill all that apply)-(Fill all that apply) (Fill all that apply) <br /> 41 Active 0 Passenger 0 Generator 0 Outdoor <br /> GPS <br /> Latitude I` I 0 Closed 0 Altered <br /> 0 <br /> __�� t�InactivIndoor <br /> e 0 Truck <br /> 0 Hauler <br /> Longitude – I �Y I I I I �O Q Planned 0 OTR 0 End-Use 19 Container <br /> Business Type (Fill all that apply) 11 <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 0 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A ,HAULING AND MANIFEST REf;QUIR MENTS <br /> Q Notico Of Violation Q Extension <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or FXTJ <br /> 0 <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB 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 In Compliance - No Violations <br /> 0 0 Other: § n <br /> Comments 1&r <br /> I iNS c NV-) <br /> a r LJ.Mf /AJO TL,- <br /> �.[S�—�/ dSGf � yS AS /71P�% I"G�iJ�G_t.cv� ��� �[4s✓/P/'/ <br /> _y_ � kcs/ �visrse,Je,,;. No ✓,_o/aTroNU—ice Conc' .,s <br /> Inspection Forth Included:0 <br /> Comments Included:0 <br /> Business Rep's Signature Phone Number Inspectors Signature one Number <br /> INSTRUCTIONS ON BACK Corre Incorrect: E X A M P L E; 1112131 62081 <br /> ■ White Copy C MB Yellow Copy.Operator Pink Copy:LEA ® ■ <br />