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rrr- <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> rrr CMMa 81 Neal"041 SurveyForm Page 1 1 9 - 1 0 1 3 01 7 <br /> art A <br /> c.I ifoui.Int.gr.t.d Wast.Management Board - g <br /> BLUE."" """ ''EN <br /> -Srvey <br /> Business Profile inspection Details <br /> 0, <br /> )0,8494 <br /> TSite SInspection Type (Fill one)PID- fx13I7U v�1 <br /> � <br /> 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local �1 �� h^� H Referral,choose referral type(Fill one) <br /> Identifier: `\J Q� �r�„ (� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name (/q Inspected By Inspector <br /> Lt 6n. �r(terKaitnla.Q 'fpe0 <br /> Phys cal Address � �j <br /> �i_0-Lao �l. �,� Zd. I o <br /> Street �j ^ O <br /> Inspection Date <br /> T/a 953'-(7mate ZIP Code I Time In Time Out <br /> -—� <br /> Business Rep <br /> _WITitle O AM :MOPM <br /> O AM <br /> M- OPM <br /> l iQSIS (#K DIS <br /> • Operational Status Tire Type Business Role Storage Type , <br /> Q{ +, (Fill one only) (Fill all that apply) (Fill all that appy) (Fill all that apply)' <br /> Tire Count(Whole/PTE) I U <br /> ®Active ®Passenger ®Generator ®Outdoor <br /> - . r ) i T O O Closed O Altered <br /> Latitude 1 I Q Hauler Q Indoor <br /> GPS <br /> L i •I )- j Q inactive ®Truck <br /> i I O End-Use Q Container <br /> Longitude - i,I I _ j 10 <br /> Q planned ®OTR <br /> Buslness Type (Fill all that appy) _ <br /> O New Tire Dealer Q Auto Repair Q Trucking Fleet O Government O Retreader Q Dismantler O Tire Derived Fuel <br /> 0 Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> O Service Station Q Hauler Q Agriculture Q Shredder ®Other 61pe Ma.wc(.-faef-tw�.+- <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility `ENFORCEMENT STATUS _ — <br /> V A HAULING AND MANIFEST REQUIREMENTS + 0 Notice Of Violation Q Extension <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m , m /m <br /> Q 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> O Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days J(Requlred for NOV or EX7) <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I 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 /> 10 O Other: § <br /> Comments <br /> ReJAhhL iK s�cC�fiQN .i.S o �i�le l! Was �'e� <br /> 11%Z5 AciUSC5 Wo Is O'n '',�M/a Wre �D ✓i c�u�is��a <br /> re� On far, Qrot <br /> 1- Q Y► <br /> e 10 in : _�)- ca-r 2r- of war �4p <br /> Inspection Form Included:(� C <br /> Comments Included:Q - ���� -- <br /> Bu iness Rep's Signature Phone Number rRrAIAMJ <br /> tor'_ nature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect:X(�q IIEIPILIEl I! 2131 62081 <br /> ■ 'Prone Copy:CI`NMB Yellow Copy Operator Pink Copy:LEA ■ <br />