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°== Waste Tire .urvey & Inspection Rep%.,,t Inspection Report Number ■ <br /> State CIWMB California I 1 - 114 0 7 2 7 <br /> • grated 7steManage Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> -t A- Survey _ __-_ _ __-_ _ _ BLUE OR BLACK INK PEN <br /> iness Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: a 3 j Q , 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local e, ►n /,,' If Referral,choose referral type(Fill one) <br /> Identifier: �)a l L/Iv \ C� ("VLQ CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ((( <br /> Inspected By Inspector <br /> G ax\c'-5 4eLk\)Lj t4au _ <br /> Physical Address J l l j� �y} Ayzw,W, <br /> Inspection Date �i -7 <br /> CA 4-52qO <br /> Time In Time Out <br /> Business Rep Title O AM77 O AM <br /> L� ® PM `J PM <br /> - - 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 /> Q Active Q Passenger ® Generator Q Outdoor <br /> Latitude <br /> O ® Closed Q Altered IA <br /> GPS A11A Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> U Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <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 O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date 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 /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 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 <br /> ® In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> gam\\ 6M CAnY✓) <br /> armor A-i 7 e In na AA 4vi i- 9. ' I P is eft <br /> 0 rn M e •?P ,D rte-`!�o� .3113 <br /> Inspection Form Included: Q <br /> Comments Included: QI - - ---- - - - — <br /> Business Rep's Signature Phone Number Ins s I n re Phone Number <br /> INSTRUCTIONS ON BACK lcwrect:I Incorrect X 1 � _ ,IW4 E62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />