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== Inspection Report Number <br /> Waste Tire Survey & Inspection Report <br /> 818. <br /> 188 State of California <br /> La11CIWMB 181(New04/04) Survey Form - Page 1 Il - 1086928 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> ! 1 I Z`J 13I I I Inspection Type (Fill one) <br /> Site Suff0 Routine Q Re-inspection <br /> ection Q Referral Observation <br /> TPID- T) <br /> Local C If Referral,choose referral type(Fill one) <br /> Identifier: San OCICV Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 1 <br /> L <br /> I M a�n Sy t-- -- S2 r�l_GE'_� 3 c, _ f d l <br /> Physical Addres l <br /> LONS Y p0- 11 <br /> Streef <br /> ,�I Inspection Date <br /> _M.Cx 1- _ — Cl JI Time In Time Out <br /> City State 7_lp Cc _ <br /> Business Rep Title (_�� ,® AM i , �I I Q AM <br /> O I,oPM ,_Ic) O O ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> G (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> v ® Active ® Passenger Generator Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive • Truck <br /> Longitude - , i Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill 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 /> ® Service Station Q Hauler Q Agriculture Q Shredder Q Other. <br /> I I , <br /> Part B- Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> MIM118WULING 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. Eompfiance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements <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 FXT) <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 C-IWMB 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 ® In Compliance - No Violations <br /> Q Q Other: § _ <br /> Comments <br /> Inspection FormIncluded: Q <br /> qF5 71 <br /> Comments Inc luded: —�� <br /> hone NeInpignjBs Rep' gna Phone Number <br /> INSTRUCTIONS ON BACK ►orre Incorrect: 62081 <br /> Exahh LE � i23 <br /> White py:C B Yellow Copy Operator Pink Copy:LEA <br />