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Waste Tire S__.vey & Inspection Repo. _ Inspection Report Number ■ <br /> California <br /> State of <br /> 8asteManage) Survey Form - Page 1 I 1 1143719 <br /> California Integrated Waste Management Board � `�J <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> iness Profile Inspection Details <br /> ID- Inspection Type (Fill one) <br /> Site Suffix: I 6 5 ® ® Routine Q Re-inspection O Referral O Observation <br /> Local \ �� q M If Referral,choose referral type(Fill one) <br /> Identifier: ` V\ 40 .`• l &UA O CHP Q CIWMB O Complaint Q Educational Visit O Other <br /> Business or Facility Name Inspected By Inspector <br /> Guy&oe'r ' I rucYA MC:� <br /> Physical Address ( <br /> 95 SS k Cc Po-tz.Ar, Avon vc- <br /> �, � �� 7/ Inspection Date 6 <br /> s�) / G Time In Time Out <br /> Business Rep Title ®AM Q AM <br /> / V 0 PM / X lJ 0 PM <br /> -- - - — Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) 1 (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> O Active Q Passenger O Generator O Outdoor <br /> O • Closed Q Altered <br /> GPS Latitude A11 O Hauler Q Indoor <br /> O O InactiveQ Truck <br /> Longitude-- — 0 Planned Q OTR O End-Use Q Container <br /> - -— --- - - - - - - - - 1---- <br /> - --- ­J- <br /> Business Type (Fill all that apply) <br /> New Tire Dealer O Auto Repair O Trucking Fleet Q Government Q Retreader O Dismantler O Tire Derived Fuel <br /> Jsed Tire Dealer Q Auto Body Q Car Dealer O Collection Q Crumb Rubber <br /> O Service Station Q Hauler O Agriculture Q Shredder ® Other 111A <br /> / A <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility <br /> ENFORCEMENT STATUS <br /> — <br /> V � A HAULING AND MANIFEST REQUIREMENTS <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires O Notice Of Violation Q Extension <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> 010 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 1 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance - No Violations <br /> 0 0 Other: § <br /> Comments � <br /> Tvvl � �r' ec�L i <br />