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ru <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CFWMC (New 181(Naw 04106) Survey <br /> CIWMB Form - Page 1 F1 9 - 10 7 3 3 3 3 <br /> C'eritomia Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- a I O Inspection Type (Fill one) <br /> Site Suffix: `/ O ®Routine .Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral;choose referral type(Fill one) <br /> Identifier: �O(,( _ _ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business.or Facility Name: <br /> Mrinspected By Inspector <br /> p,�5elr�ri�Gs lhG <br /> Physical Address <br /> 1 3/3a >�Ctrm fort �l I <br /> Street h <br /> I Inspection Date iLLLIII/ Illi SUUU[JI v <br /> City 7 State✓L ZIP Code Time In Time Out <br /> —10 <br /> Business Rep 614w-&r, <br /> 1��-&� Title F1 O AWMED O <br /> AM <br /> wrI DW Y <br /> rzm• PM GPM <br /> I_ _J <br /> --"- - Operational Status Tire Type- Business Role Storage Type <br /> U� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> IS Active ®Passenger ®Generator ®Outdoor <br /> I OQ Closed Q Altered <br /> GPS Latitude ,' Q Hauler Q Indoor <br /> IF I D Q Inactive ®Truck <br /> Longitude _ .I Q Planned Q OTR Q End-Use Q Container <br /> L t— <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection p Crumb Rubber y <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ®Other I St �( <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 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 I 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 1 Q 1 Other: § <br /> Comments JQ �- <br /> L'0�I t4tYY_Pe%etV_P ��_c� �Z ►vl (C'� C�Oo1(e73P <br /> 00—�a_1o1�ham► s- d -Thut <br /> ov_t si-re and nti I 4ire-s Were, star in qArd, _J <br /> Inspection Form Included:Q ' 196141 <br /> /,� <br /> Comments Included:®— - 13_<:2- - _q&S <br /> Business Rep's Signatu a hone umber sp ctor's I Phone umber <br /> 62081 <br /> INSTRUCTIONS ON BAC �rrect:0 Incorrect:X(J1 E AMP L E 1 'Z 3 <br /> ■ opy.CIWM Yellow Copy:Operator Pink Copy.LEA ® ■ <br />