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LSL. <br /> Waste Tire Surrey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CIWMB181 <br /> Waste <br /> eManag4) Survey Form - Page 1 I1 - 1141005 <br /> California Integrated Waste Management Board <br /> Part A- Survey_ _ - BLUE OR BLACK_ INK PE_N <br /> Business Profile I Inspection Details <br /> TPID- Inspection' Inspection Type (Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local , If Referral,choose referral type(Fill one) <br /> Identifier: San 1ppt,- l&IA Cun 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> ("OUC() <4tkc_ L w ,1x.>' 2 c-, R _ p <br /> Physical Address 1 I &r) [5 cA, <br /> '�b33 W.v�, <br /> Inspection Date I h � 0 t7 <br /> Time In �! Time Out <br /> Business Rep Title I 1 0 AM ` 0 AM <br /> l 1 b 0 P ` O � PM <br /> b n ' �6(n FVfern - -- - -- -. ---- - - - <br /> - - —-- ---i?- _- -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) y <br /> t , 0 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' 0 Active 0 Passenger 10 Generator Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use ® Container <br /> r1 - <br /> Business Type (Fill all that apply) STI�L[4j <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle I <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements DateM / M / m <br /> 010 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 00 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or E?C� <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> 0 0 Other: § t <br /> Comments} '{-�,\, �`S�Ln- [t.1347� �'J'VrfncA <br /> Ul, f_-Y% D ( 0"Cern <br /> ;Inspection Form Included: 0 Q e-� <br /> Comments Included: _ �"17=V���4Zjf �v7 �jZQJt�y�v3l 15 <br /> O Business Rep's Sig re Phone Number Inspe is Signature \ Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:18 incorrect I �/' Nt L f ! 11 <br /> 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Cop LE <br />