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Waste Tire S,, <br /> ey & Inspection Repo, . Inspection Report Number ■ <br /> aaa State of California 11 - 1143543 <br /> CIWMB181(New 04104) <br /> California Integrated Waste Management Board Survey Form - Page 1 <br /> Part A-Survey __. <br /> BLUE OR BLACK INK PEN <br /> Business Profile <br /> Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: l C) U ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: !Enan_ 1 O CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> bav�v� (.�vGl� s cdv�; LJhc1S 3 <br /> Phy sical Address <br /> Inspection DateCA j <br /> I!t7C�� o Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> ® PM � � O PM <br /> MM* Gam- -- - --- --- <br /> -- - --- -rlG �L� �S -� Operational Status Tire Type Business Role 1 Storage Type <br /> Tire Count(Whole/PTE) 9 0 <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � <br /> Active 8 Passenger ® Generator ® Outdoor <br /> O ® Closed 0 Altered <br /> GPS Latitude ® Hauler 0 Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - O Planned 0 OTR O End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler O Tire Derived Fuel <br /> ® Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler O Agriculture 0 Shredder 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V q HAULING AND MANIFEST REQUIREMENTS Notice Of Violation Q Extension <br /> 0 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O O 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7J <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 0 Referred/CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance - No Violations <br /> 1010 Other: § S <br /> Comments �C.�.11 t�_ 1ti'1�f'-f�� Pyr l•�, � "�.�I�_��.� �" 1 �� �s � <br /> - <br /> Inspection Form Included: 64r- g' <br /> Comments Included: 0 - . - -'kit, <br /> - - <br /> usmess Rep' Signat Phone Number Ins e tre Phone Number <br /> y\' 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X "� lV; I XIA M L 1 1 2 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink CopUL L A ® ■ <br />