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Waste Tire Su, - ey & Inspection Repoi l. Inspection Report Number ■ <br /> of <br /> CIWMB <br /> survey Form - Page 1 I 1 - 1127655 <br /> CIWMB 181(New 04104) Y <br /> California Integrated Waste Management Board <br /> Part A- Survey - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- _ 0 � Inspection Type (Fill one) <br /> Site Suffix: 1 0 Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: San c�a u`n C)u� <br /> u Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 Inspected By Inspector <br /> TUA 05001- 51 1 <br /> Physic Address 9 I 1 <br /> 3��3 <br /> /� Q��� Inspection Date <br /> ryTime <br /> ` S Ti <br /> me In Time Out <br /> Business Rep Title0 AM 0 AM <br /> ` OSe aPM 3 a O OPM <br /> - —- - -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f ' I* Active Q Passenger • Generator 40 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler I Q Indoor <br /> D Q Inactive 0 Truck <br /> Longitude - Q End Use Q Container <br /> 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 /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires (16 Notice Of Violation Q Extension <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� & / M10 <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 /> 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/CIWMB Enforcement <br /> Q O 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 Q In Compliance No Violations <br /> Q Q (Other: § L I ], `1.. 1 L <br /> Comments��Ll _ ` _ _��ffii1�^ 1 •�Q.. lk)asnW� <br /> oq � g _0 ] I j0j.3=/q3j0q its 0 -- <br /> Inspection Form Included: Q ` <br /> Comments Included: - �"-�+ �I - 32- <br /> mess Rep's Signature Phone Number AspVc ",Signature Phone Number <br /> � _� _.... ...__.._ 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect X �/ L � <br /> ■ --- -_.- Yellow Copy: - ® . <br /> White Copy:CIWMB Yellow Copy:Operator Pink Co y:L <br />