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Waste Tire Survey & Inspection Report Inspection fR�ep} 4C ort Number ■ <br /> [377 State of California / 1 1 1 <br /> CIWMB 181(New 04/04) Survey Form - Page 1 L 4} t i <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> Inspection Details <br /> Business Profile <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: �� �, J / C' I IV Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �j�Yl `,CJ� � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> A"�on-vn't Enkifgr► LLC, <br /> Physical Address <br /> `L <br /> /�Q� 1! _ Inspection Date <br /> �^+ ` �``' <br /> Time In Time Out l <br /> Business Rep Title AM <br /> Q AM <br /> 0 PM <br /> 7 Pm <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) f <br /> ®Active Q Passenger ® Generator ®Outdoor <br /> Latitude O Q Closed Q Altered Q Hauler Q Indoor <br /> GPS <br /> O Q Inactive ®Truck <br /> Q End-Use Q Container <br /> Longitude – Q Planned Q OTR <br /> Business Type (Fill all that apply) _ _ ---- — <br /> Q New Tire Dealer Q Auto Repair ®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 Q Other <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> A I HAULING AND MANIFEST REQUIREMENTS 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 Q 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 /> (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <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 1 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: § I_ -- <br /> Comments <br /> c C yn rn if t'l, - <br /> Inspection Form Included: Q c <br /> Comments Included: <br /> s e ep s Signature Phone Number Inspe is ig ature Phone Number <br /> — — — 62081 <br /> INSTRUCTIONS O BACK Correct:• incorrect: <br /> White Copy:CIWMB Yellow Copy:Operator Pink C p - ■ <br /> ■ <br />