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08184040101 <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> rr Stab alCall(New Survey Form - Page 1 �8 - 10 7 <br /> CIWMB tat(New 041041 <br /> C-IHomb Int.grabd w.-t.Manag.m.nt Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 , I Inspection Type (Fill one) <br /> Site Suffix: ' Q I I I 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: S C1'n 7oa9u th COU. t_c1 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name `J Inspected By Inspector <br /> ahlPhysical Address – liail i Krishan Lucus—I <br /> I <br /> G3� �er�ormtanc_e—_p <br /> Street <br /> Inspection Date <br /> I Sto <br /> Irk—ck ©r� sale zu=code..__ __GPt9_5_Zo 6; Time In Time Out G7 <br /> --- <br /> 7_1 <br /> Business Rep Title AM 0 AM <br /> O PM PM <br /> Ser,ior Vehicle <br /> Ker MZ�Caste. _ _ MQCiIO.n\C, Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 1 I (Fill one only) (Fill all that appy) (Fill all that appy) (Fill all that apply) <br /> t r 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> Latitude O 0 Closed 0 Altered <br /> GPS 0 Hauler 0 Indoor <br /> — O 0 Inactive 10 Truck <br /> Longitude – i i 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <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 S <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 4b Other L_H pt;n,rCnan C2 SCf YY C,pj <br /> Part B-Inspection of Waste Tire Dealer,Generator;Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A I HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 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 Date m / m / m <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 IX•f) <br /> 0 0 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 1 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: § <br /> Comments <br /> -It�re. rQ,N.040N Tor,,—�t^emt5es C —hav_e_been_r_e. a��z.d �9M <br /> 1 <br /> j ct_`Y_Ai�Q�t_12,—��V1e�J\Y1 u� IlkQ -F. U O (fit�o� nf�.� ��o_►1CQ.rQ <br /> I <br /> Inspection Form Included: (Z aq <br /> Comments Included:K1 . <br /> — — - <br /> ess Rep' nature Phone Number I e oes Signatur Phone Number <br /> INSTRUCTIONS ON BACK orrect.! Incorrect: gr 1jEjXjAMjPjL1E11 2 3 62081 <br /> ■ White C py CIW Yellow Copy.Operator Pink Copy:LEA ® ■ <br /> - I <br />