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Oo2�`C�C435 <br /> Waste Tire Survey & Inspection Report Jnspection Report Number <br /> sateet181INr Survey Form Page 1 I1 1088226 <br /> CIWMa 791(New 04104) Y <br /> calltomta Integrated Waste Management Boatel <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> site - MM _ �) Inspection Type (Fill one) <br /> Site Suffix: � 2 V 3 � � I Q I 0 Routine Q Re-inspection Q Referral 'Q Observation <br /> Local C / If Referral,choose referral type(Fill one) <br /> Identifier: S.41111: 'n/ (.OtJ.V g_tq- Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name �I I Inspected By Inspector <br /> l�e� 1+0 77-re s l 4 <br /> Physical Ad�ss 3 / r / <br /> L-_A_,Lx.L 1_442D��1�J <br /> Street <br /> Inspection Date 8 <br /> �5•r� �4�------C� 95zo�—, <br /> its State Zjp.,rde Time In _ Time Out <br /> Business Rep Title T Q AM j I O AM <br /> //t� / I I I•I-- _..I_.0 PM _� - (•( I _ 0 P11 <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Filloneonly) (Fill all that appy) (Fillallthat apply) (Fillall that apply) <br /> r I Active Passenger i Generator •Outdoor <br /> .o 0Closed 0Altered <br /> GPS <br /> Latitude Q Hauler Q Indoor <br /> O O Inactive Q Truck <br /> Longitude Q Planned Q OTR End-Use Q Container <br /> Business Type (Fill all that appy) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> 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 <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> O Q 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 /> 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 (Require for NOV or FXT) <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!@I Enforcement <br /> 0 Q 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 /> O O Other: § <br /> Comments <br /> /�e�.. +'�•�i�v�oe t.�F�o+� c»_ o d.�Fs .!�1u _ aw% r l Wbx& : <br /> _dA.,ff— <br /> —wa•a p� �.. r�aa /Z,�..: ��e�_r��f�... f'�e <br /> J Q---D - <br /> Inspection Form Included:01 � <br /> Comments Included:Q <br /> Business Reps nature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK orrect• ��P <br /> E X A M P L E: 1 ,2 3 <br /> ■ white opy:CIW Pink Copy LFA ® ■ <br />