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Waste Tire %1,JLrr„ey & Inspection Rep(,. t Inspection Report Number ■ <br /> CIWMB81California <br /> CIWMB Form - Pa e 1 I 1 - 1143599 <br /> California Integrated Waste Management Board Y <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ` � � (� � � � � � Inspection Type (Fill one) <br /> Site Suffix: ! I ® Routine Q Re-inspection Q Referral Q Observation <br /> Local t r If Referral,choose referral type(Fill one) <br /> Identifier: San oaDwr\n Wu� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> �� LInspected By Inspector <br /> S�;�s <br /> Physical Addresso�l <br /> -�-A o Q of V <br /> Inspection Date O 1 0 <br /> a03Time In Time Out <br /> Business Rept Title( '_ 0 AM l O AM <br /> � ® PM � d 5 ® PM <br /> - - - — - Q-- - ---- - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) p( (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �CJ Outdoor <br /> ® Active Q Passenger ® Generator Q Ou <br /> - - --o - <br /> Nip <br /> GPS Latitude Q Closed Q Altered <br /> Q Hauler Q Indoor I <br /> O Q Inactive • Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) j <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 Other <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use FacilityE O CEMENT STATUS l <br /> V I A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension � <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953 Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q 1 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements DateM / m / m <br /> 010 114 CCR§18459.1 Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <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 I* In Compliance - No Violations <br /> Q Q Other: <br /> § <br /> Comments �5.—`�1 1S1S�t �' C�(�fC1Q�, Gln- lfl� �C, S.�4f�—�--1-� Q�u—`Nr'-►��5-��V-�� <br /> �1a c51. �- 0- <br /> AAAA QCfe,Vuleriu�5- <br /> ,�o� <br /> Inspection Form Included: 411us�iNess <br /> Comments Included: ep's Ignature Phone Number Inspect s Signature —Phone Number <br /> - —-- - - - <br /> INSTRUCTIONS ON BACK Correct:0Incorrect_X i X A � f 2 3 62081 <br /> ■ <br /> Pink C9111 <br /> White Copy:CIWMB Yellow Copy:Operator ® ■ <br />