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nr <br /> Waste Tire Survey $ Inspection Report Inspection Report Numberstate ■ <br /> Stat,181 JNT Survey Form - Page 1 1 7 - 10 7 3 3 0 7 <br /> CIWMB 181 JN-nage v <br /> California Integrated Waste Management Boats <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile T— Inspection Details <br /> TPID- U <br /> I Inspection Type (Fill one) <br /> Site Suffix: U "� ®Routine Q Re-inspection Q Referral Q Observation <br /> Local �,A If Referral,choose referral type(Fill one) <br /> Identifier: Sax, �f(}� Q CHP Q CIWMB . Q Complaint Q Educational visit Q Other <br /> Business or Facility Name U /� Inspected By Inspector �"'� <br /> Physical�e IS CJ T rL UM <br /> ' Q ( L_V_CNvI/�!/_l.C �l� I S � lAx4 0 � <br /> Street Inspection Date <br /> Std cl�-n � q5 a o.s I I <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title O AM OAM <br /> eQr0 MOPM QPM <br /> - �. --- <br /> - Operational Status Tire Type. Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> r ' ®Active Q Passenger ®Generator ®Outdoor <br /> i0 Q Closed Q Altered <br /> GPS Latitude IQ Hauler Q Indoor <br /> L - - - - Q Inactive Q Truck <br /> Longitude - I- I I I I I I Q Planned ®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 /> a 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 I I <br /> Part B-Inspection of Waste Tire Dealer,.Generator,Hauler and-End-Use Facility ENFORCEMENT STATUS <br /> V I A HAULING AND 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-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 EXT) <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/CIWMB 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 1 Other: § <br /> Comments �q�,-l�%�o ins -1✓U-S <br /> k/iztvae LvIutrtCeS dor ✓2_�r5 j r( ,*-teds <br /> �s^5 f/i <br /> Inspection Form Included:Q CC _ IU�3 <br /> Comments <br /> Business Rep's Signature Phone Number �6tlsoS g ature Phone Number j <br /> �-�( 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: ( C9 X E R M P :L E!, H 2 3 <br /> ■ 07284040277 White copy:CIWMB Yellow Copy:Operator Pink Copy.LEA ® ■ <br />