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08.234040044 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of 11(Ne. I 1 — 1088163 <br /> CIWMed astleManage Survey Form - Page 1 <br /> Cat"omla Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ' S Inspection Type (Fill one) <br /> Site Suffix: Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S�q� ?Od4q� '� rDyti� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> _ 00 I <br /> Business or Facility Name Inspected By Inspector <br /> 4 44DL4_ / Q / i+�,4.� 1 <br /> Physical Address <br /> I 34-5-0 <br /> Street m <br /> Q Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title :EEO AM OAM <br /> 0 PM LH'LLJ 0 PM <br /> -- - � Operational Status Tire Type. Business Role Storage Type <br /> P, (Fill one only) .(Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(WholelPTE) j <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> --I-- --�-—`— O 0 Inactive Truck <br /> Longitude - i I, I Q Planned Q OTR Q End-Use Q Container <br /> i 1 i <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 0 Other L4w9 <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A <br /> WHIN <br /> HAG AND MANIFEST REQUIREMENTS <br /> 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. l ompliance Deadline <br /> Q Q 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 FACT) <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/C-IWMB 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 Q Other: § <br /> Commentsf <br /> Ova iiJE.—• <.t +�Y+—OYr— —OCw�¢•-.� oul�y�j �✓cr t�BT_i_i_: 9±a <br /> —�o.�-f�t�,—t�i�.��(�rc�•:�s c6.,,�b_y w�'/s�,_l�le��r�cc`/,� C7'L�.c.oY,. 200 <br /> 1- <br /> Inspection Fq.Rt�k)_Y �2 <br /> orm Included:Q O <br /> Comments Included: <br /> usiness Reps Signature Phone Number. Inspector s Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Cor Le t: Incorrect: E X a M P L E F 1 3 <br /> ■ Whit Copy_ WMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />