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Waste Tire S.My & Inspection Repo. . Inspection Report Number <br /> ■ Ili State of California ■ <br /> Cgrated 1st(New Manag) Survey Form - Page 1 I 1 - 1143789 <br /> California Integrated Waste Management Board <br /> Part A- BLUE OR BLACK INK PEN <br /> - - - _ _-- - - - - --- <br /> Business Profile Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: avi �cq�� C �i 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Businesssor Facility Name Inspected By Inspector <br /> 0"tc-5- Oc n f Y r CJYI <br /> Physical Address \ I j , A14, Ano, <br /> .60) D,Xrt( Au�' LA)et.L-f <br /> Inspection Date <br /> Lcz-f 1� C� q53303 / 0 t / / 0 <br /> Time In Time Out <br /> Business Rep Title ®AM O AM <br /> ' O PM c z O PM <br /> --- -- ----- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) frV (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> •Active 0 Passenger . Generator • Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive • Truck <br /> Longitude — 0 Planned 0 OTR I 0 End-Use 0 Container <br /> Business Type (Fill all that apply) _ <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility ENFORCEMENT STATUS <br /> - --- -- <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> j 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 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 / m / 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 0 Referred i CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators • In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments l <br /> A��-s cy- Axra-� <br /> Inspection Form Included: 0 L <br /> Comments Included: �U/ <br /> �� <br /> Business Rep's Signatur — -Phone Number Insp or' ic ature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect I 1 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink opy: ® ■ <br />