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Waste Tire Suk .ey & Inspection Report Inspection Report NumberState of al ■ <br /> CIWMB 81 (New04/o4) Survey Form - Page 1 I 1 - 114 3 9 8 0 <br /> California Integrated Waste Management Board <br /> Part A- S_UrVey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> eInspection <br /> te Suffix: , 0 RoutType (Fill <br /> a ® <br /> SiRe inspection 0 Referral 0 Observation <br /> Local �-y If Referral,choose referral type(Fill one) <br /> Identifier: )E/ �� Ca I v 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> _ Inspected By Inspector <br /> Physical Address <br /> i6�4_t E. Al 0 Iic AVC - l v l Fv,tXJ C l <br /> G AVII �SaG Inspection Date 5 1 ZJ <br /> Time In Time Out v <br /> Business Rep � Title OBAM �--. ® AM <br /> OPM Z_ O PM <br /> - <br /> �W, ,F�L Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger 0 Generator Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> 0 0 Inactive ®Truck <br /> Longitude — 0 Planned 0 OTR 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 /> 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 <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB M / M / m <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 /> 010 Other: § <br /> Comments C� <br /> Inspection Form Included 0A J - <br /> Comments Included: g �7---�1' 1 <br /> r _ <br /> Business R 's Si Oat.rUe Phone Number cto gnature Phone Number <br /> INSTRUCTIONS ON BACK Correct. Incorrect \� i E X p 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co A ® ■ <br />