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= :a Waste Tire Su :y & Inspection Report nspection Report Number <br /> ill State of California <br /> CIWMB 181(NewSurvey Form - Page 1 11 - 1140688 <br /> California Integrated Waste Management Board <br /> Part A- Survey -f p ---BLUE OR BLACK INK PEN Business Profile Ins ection Details <br /> TPID- / 2 ! / 3 _ O / Inspection Type (Fill one) <br /> Site Suffix. to h 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local C If Referral,choose referral type(Fill one) <br /> Identifier: AVN 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Aa + Go�, A�It�• �n�. � _ r � <br /> Physical Address 3 0 <br /> & <br /> Inspection Date O6A Is-2rg­ <br /> Time In Time Out <br /> Business Rep Title &AM I f AM <br /> (� 3 C) Q PM QPM <br /> --_ - <br /> (Fill oneonal only) (Fill <br /> I Fill TireTye <br /> Khat apply)j (Fill allehat apply) (Fill all e Type <br /> Tire Count(Whole/PTE) that apply)I' <br /> ® Active ® Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck rs/A <br /> Longitude — 0 Planned Q OTR 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 1 <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 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENTTATUS <br /> - S- _Li <br /> V A PRC HAULING <br /> AND MANIFEST <br /> EHaule RegistrationCRandSTrans ort of Tires 0 Notice Of Violation 0 Extension <br /> 0 0 § P <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 <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 1 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 r <br /> WrtS hv�CcA - <br /> 'Inspection Form Included: <br /> Comments Include --- - - �Sianaturqf <br /> Busine Rep's ignature Phone Number nspectorPhone Number j <br /> INSTRUCTIONS ON B K Corr ct Incorrect: X ,X1 AN 112 3 62081 <br /> White Copy:GIW Yellow Copy:Operator Pink Vt <br />