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�Q8227040282 <br /> Waste Tire Survey.& Inspection Repoli Inspection eportNumber ■ <br /> r. SblaofCallfomla Survey Form - Page 1 . 1 6 1 0 7 2 8 3 6 <br /> CIWMB 81(Naw 04/04) <br /> Callfomla InWgralad 1waste Blenag—.1 board <br /> Part A-SurveyBLUE OR BLACK.INK PEN <br /> Business Profile Inspection Details <br /> TPID- it� 4 O I Inspection Type (Fill one) <br /> Site Suffix: 1 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local -� If Referral,choose referral type(Fill.one) <br /> Identifier: San J v aq ul n COuj Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> � n an -T re Ser v►Ce I _ <br /> Physical Ae n TVA <br /> 3 9 i 0 1 LjG�is-�'i ah_L+�ensJ <br /> Street <br /> Inspection Date <br /> _La-��eP cA 933501 CJ <br /> City tate ZI ode Time In Time Out <br /> Business Rep Title O AM O AM <br /> • 'L-1-1 O PM 'FT O PM <br /> Operational Status The Type Business Role. Storage Type. <br /> Tire Count(Whole/PTE) I L.� (Fill one only) (Fill all that apply) (Fig ail that apply) (Fill all that apply). <br /> 0 Active Q Passenger 0 Generator 0 Outdoor <br /> GPS <br /> Latitude W LL 1 Q Closed Q Altered <br /> Q Hauler 0 Indoor <br /> f 0 Q Inactive 0 Truck <br /> Longitude - L� Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fin 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 0 Other ^lo�i le } Ire St?�yIce. <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility PENFORCEMENT STATUS _ <br /> V M HAULING AND MANIFEST REQUIREMENT <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violatio Q Extens on <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q PRC§42956-Registration/Decal Vehicle <br /> 0Q 14 CCR§18459 -Responsible Entities <br /> Complying with Manifesting Requirements Oate <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 Ior 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 I 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 0 InCompliance - No Violations <br /> Q Q 1Other: § <br /> Comments t-� t 1,�`T_��r-Lp-e7—�-TQYMQ[� •t�'1iS C��� _. _ 1!� <br /> l�ou�r1��J �Insl�! _ �ecL-o�a.CC10n_t;��Qa a1r�9irle5 'Lo��►n_ <br /> yt,aies c�`Lat�Qss.his�a5 ean�'t_cm_e.cl k�s�TDs_.—No mant�es� <br /> ens dj alr►� , l\�viQls Qhs a�areas o�cern,, \ <br /> Inspection Form Included:Q C2� <br /> Comments Included: �'�+ ���' Y� •31-78 <br /> usmess Rep' Signa ure . Phone Number In aYs Signatu Phone Number <br /> INSTRUCTIONS ON BACK �orrec Incorrect: X A M P L E l 2 3 62081 <br /> ■ - W hit Copy Yellow Copy:Operator Pink Copy LEA ■ <br />