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Waste Tire Survey & Inspection Report Inspection epo umberstate <br /> ■ <br /> cfWMB ILII Nmla Survey Form - Page 1 1 8 - 10 7 9 10 7 <br /> CIWMB 181(Now OUW) <br /> Call/omla Integrated Wast.Management Bard <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- n - O Inspection Type.(Fill one) <br /> Site Suffix: F <br /> Lk L 0 Routine O Re-inspection 0 Referral Q Observation <br /> Local H Referral,choose referral type(Fill one) <br /> Identifier: I San �o QquI n CoL)Ls 'y Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name d <br /> Inspected By Inspector <br /> L_—T_T <br /> Physical Address - <br /> LK_risl'i4n L.ucaS� <br /> Street <br /> y/y� Inspection Date <br /> ����` C 9'5Z "O� Time In J Time Out <br /> City State ZIP Cooe <br /> Business Rep Title C O AM O AM <br /> T1Qf%maq OT m'ED O PM O PM <br /> w)C'. <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) 6J 2 <br /> 0 Active Q Passenger 0 Generator 0 Outdoor <br /> GPS Latitude _W-LLL�O O Closed Q Altered O O <br /> Hauler Indoor <br /> _ 0 O Inactive 0 Truck <br /> I <br /> Longitude - I 0 Planned Q OTR C)End-Use Q Container <br /> Business Type (Fill all that apply) �J <br /> O New Tire Dealer O Auto Repair 0 Trucking Fleet Q Government O Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer 0 Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler. O 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 <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires O Notice Of Violation Q Extension <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O Q 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> 0 Q 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or FXn <br /> OO -- - <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers p Referred I CIWMB .Enforcement <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance'- No Violations <br /> Q Q 1 Other: § <br /> Comments <br /> gouflne ti�.s-psst►s�crn_Per armed -H,►s �c e flu n1Lw_i t�qs cafq3: <br /> 1.10 vao\o�t�ons oc_nr_egS o�concR.r_�r�-eked—s�i5 �cc1.lt —asp cS o�fixe_ <br /> ( ate �_aSkP 7b ye _N%*'1 'C'24�— ., — i <br /> 't9r LQs >e-G�io_CL <br /> Inspection Form IncludeQ r <br /> (20°I1 <br /> �c39 39 O(o - 'ihs i-7 <br /> Comments Included:d:Q - — <br /> Business Rep's ignature Phone Number ctors Signatur _ Phone Number <br /> INSTRUCTIONS ON BACK Ar c : Incorrect: ( X A M P L E 2 3 62081 <br /> ■ - White Copy ZM Yellow Copy Operator Pink Copy.LEA ® 0 <br />