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082SSO40013 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> srt.B 181(Nmla 1.1 ' -. 10 8 817 4 <br /> CIWMB 18asteM nageW04) Survey Form - Page 1 <br /> Glltomla Integrated Waste Management Board ._ —__—. <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- - a --� / - _ I-.,e�- -- Inspection Type (Fill one) <br /> Site Suffix: D 5 I ( (G I F/ ! Routine Reins ection Referral Observation <br /> -� 1 - - _ 3-- • o p o 0 <br /> Local I I If Referral,choose referral type(Fill one) <br /> Identifier: i �ArJ Te .� � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> cam,.`r ;-,- <br /> Physical AddressI f i — I I_'i <br /> Inspection Date - --- <br /> C� 952t�5' p i D ©! <br /> ----- _ -------- ---.-.-__. _-- - Time In Time Out <br /> Business Rep Title - - - -- -- O AM - O AM <br /> B( o <br /> O PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(W hole/PTE) [/ ' (Fill one only) . (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> t <br /> *.Active Q Passenger •Generator •Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude _ Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned 0 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 Dismantler Q 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 it Other L44w ,� Qe <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 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 /> Q O PRC§42956-Registration/Decal in Vehicle <br /> O o 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> o O 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> Q o 14 CCR§18459.2.1-Submittal of Comprehensive Trip Log's within 90 days (Required for NOV or EXT) <br /> o O 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 Q Referred 1 CIWMB Enforcement <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> o Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators i In Compliance - No Violations <br /> 1010 1 Other: §, -.. .._-- - <br /> Comments o'er A"e- %AI.9p <br /> k46--2 <br /> �)4�.�err t 7/<Q Gi0 / ��j i a9.-✓ T7/� <br /> _ 0 <br /> inspection <br /> Inspection Form Included:Q <br /> �8 9G L <br /> Comments Included:Q <br /> BusInesvAeprsNignature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BAC Corr t: Incorrect: (� EIIXIAIIM P t E I I i 2 3 62081 <br /> ■ hite Copy. M Yellow Copy.Operator Pink Copy.LEA ® ■ <br />