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082502050030 <br /> « , Waste Tire Survey & Inspection Report Anspection Report-Number <br /> State or181(Ne. Survey Form Page 1 I1 - -1088257 <br /> clwale rat(new oaosi \/ <br /> LNaomla Inuerarad Waata Manapamam Board J <br /> Part A-Sur BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Inspection Type (Fill one) <br /> ffi <br /> Site Sux: ' ili Is 13 1 §R 0 Routine O Re-inspection O Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. 5A� J DA r� O CHP O CIWMB O Complaint O Educational Visit Q Other <br /> Business or Facility Name V Inspected By Inspector <br /> PhysicalAddress ) WALDVJ <br /> 1A VZ t72 1 <br /> Street Inspection Date <br /> -119—J�Z � <br /> City Sts!e o Time In Time out <br /> ZIP e <br /> Business Rep Title i I O AM I —� O AM <br /> Vavn Ho 4ove-r �---'�' L- O PM o PM <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 /> 10 Active 0 Passenger 0 Generator 0 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude I O Hauler O Indoor <br /> O Inactive O Trude <br /> Longitude - Q Planned Q OTR 0 End-Use Q Container <br /> Business Type (Fill all that apply) - <br /> Q New Tire Dealer Q Auto Repair 0 Trucking Fleet Q Government Q Retreader •Dismantler 0 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 Q Other I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I G AN E RE• I MEN <br /> Q 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 /> O O. 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 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 /> O O 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 Q Referred/GIWMB Enforcement <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14.CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q O Other: § <br /> Comments (�_ /W C .P.e7i�M 01•� 'a'K�e D� <br /> /t lTLsa —LSP <br /> _%Zta:. �a,`.'.[,�'d,)_,�.a..�—A�t �a�a,,.__as i7.�.,-:,► ��s}--�.r� 7�i��Gta.,,�, <br /> � �e�—•��!Vo V��c7 t'o a+n J or ��.rsn���s �o2>i.�. <br /> Inspection Forth Included:Q •\ `� �� O <br /> Comments Included:o azn 3- <br /> Business Rep's.Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correet: neorrect: L E"X AjM P 1 2 3 62081 <br /> ■ White Cy'CIW MB Yellow Copy.Operator Pink Copy.LFA ■ <br />