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08U1t2��01�� <br /> cee- <br /> Waste.Tire Survey &.Inspection-Report Inspection-Report.Number <br /> State Millis161(Nola Survey Form- Page 1 13 . 1 0 7 3 4 8 4 <br /> CnvMe ass ew oage <br /> cautomialntegratedwasteMamgemanteoani BLUE OR BLACK INK•PEN <br /> Part A-Survey <br /> Business Profile. Inspection Details <br /> TPID- --/ q m Inspection Type (Fill one) . <br /> Site Suffix: (� T I d I 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Sa y� TD kri CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 1 v ggg inspected By Inspector <br /> Physical Lreeb <br /> Street ^A 9 J Inspection Date <br /> i6d <br /> tl�� State SZI Time In I Time Out <br /> Business Rep Title m m0 Am 0 AM <br /> PM m m PM <br /> _ _ _ Operational Status Tire Type Business Role Storage Type <br /> L� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE), ,: �� T� <br /> I 0 Active Passenger 0 Generator 0 Outdoor <br /> ( O 0 Closed 0 Altered <br /> GPS Latitude , 0 Hauler ,;Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use Container <br /> Business Type (Fill all.that apply) <br /> ®New Tire Dealer ®Auto Repair—0Trucking Fleet 0 Government 0 Retreader. 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORC-EMENT STATUS <br /> V I A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice of Violation <br /> 0 0 0 Extension <br /> PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts.with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 Submittal of Comprehensive Trip Logs within 90 days (Required for OV or <br /> 0 0 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 0 Referred f GIWMB Enforcement <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System.Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> 0 0 Other: § /All <br /> (� <br /> Comments <br /> aI IY� y l�—fes '�-i,-t � /Al /' L <br /> rL.rJrr� o� �"fit__LL���b�S�ti✓'ra/ .i� Gari,frJ�•rc¢A��� v' �,zN+C <br /> Inspection Form Included:0 <br /> Comments Included:0— fir/ 6� D62 <br /> Busd ess R P's Signature Phone Number T.-.p.ctor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:+, IncoI X AIM P L E i 1 2 3 620B1 <br /> rrect: <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA ® ■ <br />