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Waste Tire Se & Inspection Reogo Inspection Report Number <br /> -i Y p p <br /> State of California I 1 - 1140652 <br /> CIWM6181(New 04104) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> - BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> Business Profile Inspection Details - <br /> TPID- L� L Inspection Type (Fill one) <br /> Site Suffix: I ( O ( ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: sav Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name c Inspected By Inspector <br /> Physical Address <br /> Avem a_ <br /> Inspection Date ' LI� <br /> E.sCo J c� �� R53�0 �✓ <br /> C/ <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> _60 PM 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 /> a Active Q Passenger I®Generator ® Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> 0 Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q 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 Other <br /> -- —ATUS -_ --- <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility r ENFORCEMENT <br /> V A j HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> O O <br /> 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 /> O O j 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements DateM / m / m <br /> O O 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O - - - - - <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q O 114 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: - — ^-` =`--7`--Agntur, <br /> Bu ' ess ep's Signat Phone Number Phone Number <br /> INSTRUCTIONS ON BACK Correct * Incorrect ' 11262081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink C py:L <br />