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- 0&066040002 <br /> ointWaste Tire Survey & Inspection Report Inspection Report Number <br /> cfate of WMs1aldOmleSurve Form-- Pa e1 16 - 10 7 3 4 0 5 <br /> CIWMB 181(New OGga yegrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK.INK PEN <br /> Business Profile <br /> —l— Inspection Details <br /> TPID- I �—,—T_-T—j In Inspection Type (Fill one) <br /> Site Suffix: II I I I 1 I I - V� ®Routine QRe-inspection QReferral <br /> Q Observation <br /> Local H Referral;choose referral type.(Fill one) <br /> Identifier:. LG/��n^r��� v� Q CHP', Q CIWMB Q Complaint Q Educational Visit Q Other. <br /> Business oo�rrQFacility Name Inspected By Inspector <br /> Ph'—ysical7�dd�� fck- <br /> e- - __ I 3 R - l r T _ <br /> 10,q0 S, ckrAa _ --- <br /> Street <br /> 1 <br /> /1tg, r O Inspection Date. <br /> y t� <br /> City State ZIP Code Time <br /> min Time Out <br /> Business Rep Title <br /> ED <br /> O PM m m O PM <br /> Ope--ratiioonaall(Status Tire Type Business Role Storage.Type <br /> i ) I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply), <br /> Tire Count(Whole/PTE) 'I ]I <br /> ®Active ®Passenger ®Generator .®Outdoor. <br /> 0 Q Closed Q Altered <br /> GPS Latitude �• I Ll Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container- <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q.Trucking Fleet Q Government Q'Retreader Q Dismander Q.Tire'DeriVed Fuel <br /> Q Used Tire Dealer Q Auto Body ®Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other L I <br /> Part B-Inspection-of.Waste Tire Dealer,Generator;Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V AI-HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q 0- 14 CCR§18459 -Responsible Entities Complying With Manifesting Requirements Date m / m / m <br /> Q Q 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 /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®in Compliance - No Violations <br /> Q Q Other: §. <br /> Comments <br /> VIo Z `n s naed - (Two Tpa*s oss'ghed fo 5rlte. Close TP)& <br /> Inspection Form Included:0 c Q�Q(�/_/ <br /> Comments Included:Q �67-& 7� �U-s!( & <br /> A.I. .. e ' nature Phone Number Inspe s Signature Phone Number, <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: (( . x M P ;L E 1 l :2 3 62061 <br /> ■ Copy.CIWMB Yellow Copy'Operator Pink Copy:LEA <br /> ®White ■ <br /> ,_ I <br />