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ue_ <br /> Waste Tire SurveyA Inspection-Report Inspectio gRp°IliAU0AMrr � <br /> rr .rwSmamB181(Now Survey Form Page 1 11 5 1 0 7 9 4 6 7 <br /> Cg,ll 181(Naw01/00 <br /> Celllomia Integrated Waete Management Board <br /> Part A-Survev BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: .1.3 I `� l cJ 11 2 I ®Routine Q Re-inspection Q Referral Q Observation <br /> Local. If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> BusinessorFacility Name Inspected By Inspector <br /> Physical Address -3 9 d I /► le�_`� +N e.�) <br /> Street <br /> Inspection Date / <br /> ] I S2_ <br /> Z-y O i <br /> City Lir State ZIP Code Time In Time Out I <br /> Business Rep Title O AM O AM <br /> O PM O PM <br /> jr Operational Status Tire Type Business Role Storage Type <br /> I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE):r ( t <br /> ®Active ®Passenger 0 Generator Q Outdoor <br /> i <br /> rI OOQ Closed Q Altered <br /> GPS Latitude Q Hauler Q <br /> Indoor J � QInaive Q Truck <br /> Longitude I _ _ _LLL � Q Planned ®OTR Q End-Use Q Container- r <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 /> i <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> 1 Q Service Station Q Hauler Q Agriculture Q Shredder • ®Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V 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 DCT) <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 Other: §, <br /> Comments '�'y� ' <br /> ��.,,.�• t n S-�pc�.,f;.u.- Ov`- '��'S_ ��S— —/_.'rc�te�te/ <br /> —�G�'C.�w�Gcb�l—Gvltirl�-�'I.K=6�tt�fLtQ CiT�.cg-1,7-i:yt-vQ�rcC—�/tc.•�.,� --- <br /> u�no•, r-Y�.1.c-SSI� /l/�d'—aL�-►�ryr�_ <br /> Inspection Form Included:Q. 6 2 S <br /> Comments Included:Q ��(( — <br /> Buslrlee4(tepjbr Signature Phone Number spector's Signature Phone Number <br /> • X� grIiiiiiiiiG11172131 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A M P L E' j <br /> ■ White Copy CIWMB Yellow Copy.Operator Pink Copy.LEA <br />