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Waste Tire Sui „ey & Inspection Report Inspection Report Number ■ <br /> e,a State California Survey Form - Page 1 I 1 - 1143472 <br /> �r CIWMBB 181(New 04104) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> ' TPID- � � � � l � � - Q 1 Inspection Type (Fill one) <br /> Site Suffix: d. I 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local1 If Referral,choose referral type(Fill one) <br /> Identifier: San 104, <br /> �1 rl O CHP Q CIWMB Q Complaint O Educational Visit O Other <br /> Business or Facility Name Inspected By Inspector <br /> `s,C. rl�U1,VJ7 ( 3 <br /> Physical Address <br /> W . Afl�C.s->CVN �- <br /> `� Inspection Date `7 <br /> � I <br /> 4�b e'4 b.n ` Time In Time Out f <br /> Business Rep Title i 10 AM 1 `� Q AM <br /> �01nr1 Q PM t J PM <br /> i v un <br /> Cc_rk(_s I --- <br /> - - - - - - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger i Generator 9 Outdoor <br /> 0 0 Closed Q Altered <br /> GPS Latitude O Hauler Q Indoor <br /> D O Inactive 6 Truck <br /> Longitude - O Planned Q OTR O End-Use Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer O Auto Repair ® Trucking Fleet Q Government Q Retreader O 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 O Other <br /> V rt B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> A HAULING AND MANIFEST REQUIREMENTS <br /> 0 O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of Violation Extension <br /> 0 O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date / m / m <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 O 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 1 O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 1 Q Referred/CIWMB Enforcement <br /> Q 1 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> Other: § --- - -- - -- <br /> CommentsWN <br /> 1 I <br /> J <br /> j ---- <br /> Inspection Form Included: 01 <br /> �,^[�i <br /> Comments Included: ® + �� `J " <br /> usi ess Reps Signature Ph r Ins ector Signature pT( n i <br /> p g one Number p 9 o e Number <br /> INSTRUCTION ON BACK Correct:* Incorrect l 9C A L11213162081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C py: E ® ■ <br />