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08188040006 <br /> L Waste Tire Survey & Inspection Report Inspection Report Number <br /> State en. <br /> ;a <br /> CIWMB <br /> SurveyForm Page 1 I 1 - 1108428 <br /> GWMB 181(New nage � � �— <br /> Californla Integrated Waste Management Board - <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- j - Inspection Type (Fill one) <br /> ffi <br /> Site Sux: 1 9Aj P i !- 0 Routine b Re-inspection 0 Referral 0 Observation <br /> Local �l t If Referral,choose referral type(Fill one) <br /> Identifier: i SAn Jo LUA {l _� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> L1�b vN �,=� <br /> . 1� 1� <br /> LAAD <br /> i-;;•, / �a Inspection Date O <br /> — " qv) - -- — — � - ,'C-;^� <br /> Time InV Time Out <br /> Business Rep Title Q AM _ ' ; -- Q AM <br /> rr <br /> Cl�5�1 I <br /> 0 OPM ' i 3 O * PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 16 (Fill one only) (Fill all that appy) (Fill all that apply) (Fill"all that apply) <br /> f f Active 0 Passenger 0 Generator 0 Outdoor <br /> D 40 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned OTR 0 End-Use 0 Container <br /> Bvsw�ss Type (Fill all that appy) <br /> 0 New Tire Dealer 0 Auto Repair 0.Trucking Fleet 0 Govemment 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other rn(�(� f _ f �I <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires - ice Oiolation <br /> f V0 E•xte Sion <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. In liance Deadline <br /> 0 0 PRC§42956-Registration/Decal tVehicle m <br /> 0 0 14 CCR§18459 -Responsiblesible Entities Complying with Manifesting Requirements t) t <br /> 0 0 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days ( equired for NOV or DC7) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Referred/C-IWMB Enforcemen <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In C-ompiiance - No Violations <br /> 0 0 Other: § _- <br /> Comments h-0 t1M1►5. _101\ _ ni IS A aA&7 — —V in _ 5 1101 <br /> -- ' <br /> N .: l---F�a ��_ V• s w�.5CA. ';J�-� <br /> �_._ ��;Le�arc,�1� ec1c�� -f� ��n►s �r,�i}' <br /> Inspection Form Included: L&Ar-. <br /> Comments Included: {I`p_`IU J•�I <br /> Business" i natur e fs Phone Number InspSignature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK C ect: Incorrect: E X A IM P I L E. 111251 <br /> White py.CI Yellow Copy Operator Pink Copy LEA <br />