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Waste Tire Su. .ey & Inspection Report. Inspection Report Number ■ <br /> State of <br /> 811fornia(New 04104) Survey Form - Page 1 I1 - 1143534 <br /> California Integrated Waste Management Board Y g <br /> Part A. Survey---._- BLUE OR BLACK INK PEN <br /> Business Profile 1,Inspection Details <br /> TPID- q /(� Inspection Type (Fill one) <br /> Site Suffix: 2 g a 0 t V ® Routine Q Re-inspection Q Referral Q Observation <br /> Local �\ t �, If Referral,choose referral type(Fill one) <br /> Identifier: San J qI n (0 n � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> q11 \�� Inspected By l Inspector <br /> (a4rcAn5 �M.Kn(.Y1�G�(� 1 10t��wY1Z�. ,�LLP(� I - l <br /> Physical Address ben ESCO40 <br /> ILo3 S . g Shy <br /> 11"I Inspection Date <br /> 54 Gtvpn CA g51o(o <br /> Time In Time Out <br /> Business Rep Title 0 AM <br /> //'� j 1 l f <br /> V V O PM 1 V O PM <br /> -------- — ��m5 r'-- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) L 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> t ® Active ® Passenger 0 Generator ® Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive ® Truck <br /> Longitude — Q Planned OTR Q End-Use 1 Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet ® 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-1 A I HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 / m / m <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 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 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 <br /> e In Compliance - No Violations <br /> Q Q Other: § 1 <br /> Comments �rQ(] W <br /> o v iota l�ns �s�Le�s vi concern <br /> jInspection Form Included: Qj <br /> Comments Included. 4. � O <br /> Business Rep's Sin ure Phone Number Inspe r s Signatur hone Number <br /> - - 62081 <br /> INSTRUCTIONS ON BACK Correct. Incorrect A ' ¢ t <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co y:L <br />