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Waste Tire Sur . .:y & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CNVM13 181(New 04104) Survey Form - Page 1 I 1 - 1127504 <br /> California Integrated Waste Management Board <br /> Part A- Survey-- BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> - - <br /> TPID- ; !Inspection Type (Fill one) <br /> Site Suffix: Q rQ t ® Routine Q Re-inspection Q Referral Q Observation <br /> Local �� If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or FacilityName <br /> Inspected By Inspector <br /> Phy�IQC�,Yv�,6 <br /> sical Ad ress <br /> ISE Q)_ LOc),�,e AV—P— <br /> q5 Inspection Date <br /> �� <br /> Time In l l Time Out <br /> Business Rep Title � , O AM O AM <br /> . D O D 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 /> ®Active ® Passenger ® Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPs Latitude Q Hauler ® Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use i Q Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer •Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® 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 /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q O 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 / 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 /> 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 114 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 16 <br /> In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> A) b�r rl l6y)c�ern <br /> I D r kv <br /> Inspection Form Included: QI _ <br /> Comments Included -- -- -- -- <br /> Bu ess Rep's Signature Phone Number I ctor s gnature Phone Number <br /> INSTRUCTIONS ON BACK Correct. Incorrect /! j �I'� 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C y: ■ <br />