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3. <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> stateS Ne I1 1088056 <br /> CIWMB 18astew 0age Survey Form - Page 1 <br /> Cagromia Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / Inspection Type (Fill one) <br /> Site Suffix: O - O ( #Routine Q Re-inspection Q Referral Q Observation <br /> Local � /n• If Referral,choose referral type(Fill one) <br /> Identifier: C...J��-A, U `iC�� 0 CHP Q CIWMB Q Complain) Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> � �n /1 Q�^ _ Inspection Date O y / O 3 O <br /> 1` /l/1�t Y V=1`t//l Time In Time Out <br /> Business Rep Title /� J' [� O AM /`1 ®AM <br /> C) <br /> 'r <br /> 0 PM v 0 PM <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 appy) <br /> ,( 0 Active Q Passenger *Generator 0 Outdoor <br /> O 0 Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O ' Q Inactive ®Truck <br /> Longitude - 0 End-Use Q Container <br /> 0 Planned Q OTR <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 0 Hauler Q Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS _ C)Notice Of Violation 0 Extension <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 10 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 m <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 NOV or EXT) <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 Referred I CIWMB Enforcement <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance - No Violations <br /> 10 0 Other: § <br /> Comments �io, .R iG C © S � �l /L <br /> m an;�s- - fornns v;e&,veol �o"rceV s <br /> Vi p( _ 8nS <br /> Inspection Form Included:Q <br /> Comments Included: rPhone <br /> 9/ T ----- --—---- r <br /> Business Rep's Si tNumber Inspector" i�nature Phone Number <br /> X �/ T L I ! [�TT1-1 62061 <br /> INSTRUCTIONS ON BACK Co ct: a= X Ii M P L 1 2 3 ® ■ <br /> Vhl.G q�y CIW h ,e i Cape G afar Pink Copy:LEA <br />