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012620:50015 <br /> a <br /> Waste Tire Survey 8t: Inspection ReportInspection Report Number <br /> gW aotCa ra nla Form - Page 1 12 - 01 0 660 <br /> ctwn+s,er(New Due<> Surveymtegmted W.V.W-g--t Bea d _ SLUE OR BLACK INK PEN <br /> Part A Survey_ _ inspection Details <br /> IBusiness Profile <br /> r� Inspection Type (Fill one) <br /> TPID 3 I - ! ® Q <br /> Site Suffix: <br /> I Routine Re-inspection Q Referral Q Observation <br /> if Referral,choose referral type(Fill one) <br /> LocalC/y r,� �Q Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Identifier: - <br /> Business or Facility Name U V Inspected By Inspector <br /> fa, W reckAns 3 - <br /> Physical Address _ <br /> I /U( I <br /> Street U Inspection Date Q <br /> L]! u�/ c 1 Time In Time Out <br /> rt— State de (� O AM El <br /> m OAM <br /> usiness Rep Title O PM ( O pM <br /> u OperationalStatus Tire TypeBusiness RoTe <br /> t (Fill one only) (Fill all that apply) (Fill all that ap <br /> Tire Count(WholelPTE). r r �j ®Active ®Passenger ®GeneratO Q Closed Q Altered <br /> Q Hauler <br /> Latitude ®Truck <br /> GPS ' _ _ _ _ r_—- -,0 0 Inactive <br /> Longitude - I Q Planned Q OTR <br /> Q End-Use Q Container <br /> Business Type (Fill all that apply) Dismantler Q Tire Derived Fuel <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q <br /> Government Q ReUeader <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station .Q Hauler Q Agriculture <br /> Q Shredder Q Other I i <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS - <br /> V A HAULING ANO 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 /> Q Q PRC§42956-RegistratiorUDecal in Vehicle FTI Q Q 14 CCR§16459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB (Required for NOV or EXT) <br /> 0 <br /> 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days F _ <br /> Q O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years O Referred 1 CIWMB Enforcement <br /> Q 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <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 /> ��,/.. l � <br /> [;Comments (SCS tJ rt 2 (—�UL r�O- <br /> >�u+ 'o F <br /> '�1`reS !h sic�_v2k.i-C�2�� 0 � S , %Jlre�_ <br /> all �gft <br /> Inspection Form Included: <br /> y lvg-q9( <br /> LComments Included:Q I nature ne Number �L Inspe s Slgn Phone Number <br /> . usiness Rep' g - 62081 <br /> INSTRUCTIONS ON BACK Correct:9 Incorrect: ( �j E K P L e 1 2 3 ■ <br /> 0 <br /> White Copy:C1W MB Yellow Copy Operator Pink Copy:LEA <br />