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Waste Tire Su. .ey & Inspection Report. Inspection Report Number ■ <br /> State California I 1 - 1143850 <br /> CIWMBB 181( e ) Survey Form - Page 1 <br /> California Integrated WasttManagement <br /> Waste Management Board <br /> Part A- Survey_.__----- BLUE OR BLACK INK PEN <br /> Business Profile ,Inspection Details <br /> TPID- Q ~-� Inspection Type (Fill one) <br /> Site Suffix: 8 / ( ® Routine Q Re-inspection Q Referral Q Observation <br /> Local . If Referral,choose referral type(Fill one) <br /> Identifier: �� v�� v, L Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> A It M Avfc Oi';may\+te r5. - - 1 C) 1 l <br /> Physical Addressel <br /> � m <br /> 11=( `a . 1 00 fckUO <br /> { Inspection Date C2 D 1 <br /> Time In Time Out <br /> Business Rep Title 0 AM 2 0 AM <br /> Az-",Y" ® PM �J 0 PM <br /> SYYY;Ii_�d~ dC-Jne 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 /> Active is Passenger ® Generator O Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader •Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS _ <br /> H <br /> A <br /> Q Notice Of Violation Q Extension <br /> HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q 10 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 00 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance - No Violations <br /> Q Q Other: § <br /> Comments 7% t� L�!�[�,� J�j /�"t <br /> v" �_� C1 z. , <br /> AGY <br /> Inspection Form Included: QA�l <br /> C? p <br /> Comments Included: Q, - - - - -- - - - -- -- -- <br /> Business Rep's Signature Phone Number *C. f/ <br /> Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect ,! t I � 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator t V I ® 0 <br />