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08010040205 <br /> Waste.Tire Survey & Inspection Report inspection Report Number <br /> ' Btat°°'`allta. Survey Form - Page 1 13 - 1 0 7 3 3 8 5 <br /> CIWMB 181(New 04104) <br /> c'Mome Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK-INK PEN <br /> Business Profile . Inspection Details <br /> TPID I 0. 7 ,� S `I 1 . O I Inspection Type(Fill one) <br /> Site Suffix: ®Routine Q Re-inspection Q Referral Q Observation <br /> Local N Referral,choose referral type(Fill one) <br /> Identifier: !J({Iti �pQr�t�; Q CHP Q CIWMB Q Complaint .0 Educational Visit Q.Other <br /> Business or Facility Name <br /> T Inspected By Inspector <br /> &Lrk_ 15 t ifs <br /> Physical Address <br /> I 18 tJ Ave I - - <br /> Street <br /> ^5 Inspection Date(n/' I Time In / Time Out <br /> rty Stare ZIP Code <br /> Business Refp�/� Title O AM Q AM <br /> L—!1 J-4.'Ir 1� —OW V� t m•m 0 PM m m 0 PM <br /> Operational Status Tire Type - 'Business Role.• Storage Type <br /> T (Fill one only) (Fill all that apply). (Fill all that apply). (Fill all that apply) <br /> Tire Count(Whole/PTE) �. <br /> '®Active ®Passenger ®I Generator. . -®.Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude – =.H <br /> Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> (®New Tire Dealer ®Auto Repair .Q Trucking Fleet Q Government Q Retreader IODismantler Q Tire Derived Fuel <br /> (e 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 ENFORC-EMENT STATUS- I <br /> V A HAULING 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. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <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 (Requi ed for NOV or F,CTJ <br /> Q 014 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 1 Q 1 Other: § _y/ <br /> Comments �itlt- imspe.G1iDh /Yu-5 date. `rkQ -ryll Wjyy i(AS yio-'e ar A'(` <br /> i."k& r)o&n SLP/bluds Fbf- ir9_ EDS- yy akv Fest% <br /> (.ewoedT,-p- Pr ra Ctll�s cf.L S sed a (.t:`tAt°s-k;ba� /• A/t) <br /> V i o a�fic:�S <br /> Inspection Form Included:QQ CJ p <br /> Comments Included:Q — <br /> B siness Rep's Signature Phone Number Inspects s Signature Phone Number <br /> ' <br /> INSTRUCTIONS ON BACK Correct:(' Insorreet: E. R A M P J_ 111213 62081 <br /> . White Copy:CIWMB Yellow Copy.Operator Pink Copy.LEA ® ■ <br />