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09210040:478 <br /> WHA-Waste Tire Survey & Inspection ,Report Inspection Report Number ■ <br /> i State ClWMBteO <br /> of CaliforniaCaliforniala T 108690 0 8 6^VJ 0 <br /> California lntigratedWasteManagementBoard <br /> Survey Form- Page 1 1 FVC <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile ��� Inspection Details <br /> TPID- t I Q ^ ') _ L Inspection Type (Fill one) <br /> Site Suffix: ` l L/ 'Lt ® Routine Q Re-inspection Q Referral Q Observation <br /> Local ` �,� If Referral,choose referral type(Fill one) <br /> Identifier: San Soca J� (CLA-1 O CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or FacilityName Inspected By Inspector <br /> �flS rI � � 1 0 1 <br /> Physical Address — <br /> Street © l I l o <br /> JC3 � Inspection Date <br /> � <br /> City StattRl,�Z5de J <br /> CTime In Time Out <br /> Business Rep Title `` ( �] O AM -I� rJ^ Q AM <br /> 1/ \ I� f LO ! I®PM � J` I� OPM <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 0 Passenger •Generator ®Outdoor <br /> Latitude DQ Closed 0 Altered <br /> GPS <br /> Q Hauler Q Indoor <br /> p Q inactive ®Truck <br /> Longitude - Q Planned OTR 0 End-Use Q Container <br /> i <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ®Trucking Fleet 0 Government Q Retreader Q Dismantler 0 Tire Derived Fuel <br /> Q Used Tire Dealer 0 Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> 0 Service Station Q Hauler Q Agriculture Q Shredder Q Other I I <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 /> 0 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation 0 Extension <br /> 0 Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or E>M <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® in compliance - No Violations <br /> 0 Q Other: § <br /> --- <br /> CommentsC�C� I 1 1 <br /> (C2 1/12)1 �A 4Z!� <br /> Inspection Form Included: AI^Cr <br /> Comments Included: Q <br /> Bu in s Rep's nature Phone Numbe Ins"es S' lure Phone Number <br /> INSTRUCTIONS ON BACK C rrect Incorrect: ] ( ) EXAMPLE 1 ,2 3 62081 <br /> ■ White Cop .CIW B Yellow Copy.Operator Pink Copy.LEA ® ■ <br />