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Waste Tire "y & Inspection Repoi#lnspection Report Number ■ <br />It9 State of California T 1 <br />ew 04104) <br />California Integrated I i Waste Management Board survey Form - Page 1 1127710 <br />Part A - Survey- - _ BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />TPID - � � � � � � � � I Inspection Type (Fill one) <br />Site Suffix: ® ® Routine 0 Re -inspection 0 Referral 0 Observation <br />Local, If Referral, choose referral type (Fill one) <br />Identifier: San 5o a qUAn C(Xk 1j 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br />Business or Facility Name J <br />Inspected By Inspector <br />Physical Address <br />3()D, M - C61f06;t L(), <br />Inspection Date 1 C) r„ D <br />L� i ( A S�'-1� 666 V <br />Time In Time Out <br />Business Rep Title [A O AM o 0 AM <br />-t � QPM a � QPM <br />OCAn� 5 C�(nn 1 Rn Vuoncr <br />- - - - Operational Status Tire Type Business Role Storage Type <br />Tire Count (Whole/PTE) <br />I ^ (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br />U <br />® Active 0 Passenger 0 Generator 0 Outdoor <br />O 0 Closed 0 Altered <br />GPS Latitude 0 Hauler 0 Indoor <br />O 0 Inactive 0 Truck <br />Longitude - 0 Planned 0 OTR 0 End -Use 0 Container <br />Business Type (Fill all that apply) <br />New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader <br />® 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 <br />V A I HAULING AND MANIFEST REQUIREMENTS <br />0 0 PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 0 PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 0 PRC § 42956 - Registration/Decal in Vehicle <br />0 0 14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 0 14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />0 0 14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <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 <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 <br />010 1 Other: § <br />Comments 0 1. 1 _ Lt_ _ C r, Al_ ! - I L _ I J1 <br />N v o1u►-D� S -_or Ccufsczns�,rn <br />nspection Form Included: <br />Comments Included: <br />Phone Number <br />INSTRUCTIONS ON BACK Correct: 0 Incorrect <br />■- -- - - <br />-White Copy: CIWMB Yellow Copy: Operator Pink <br />V vianianucI lj I Ire uenveu Fuel <br />ENFORCEMENT STATUS <br />0 Notice Of Violation 0 Extension <br />Compliance Deadline <br />Date <br />m/m/m <br />(Required for NOV or EXT) <br />0 Referred / CIWMB Enforcement <br />In Compliance - No Violations <br />r � ' <br />00J1 -3173 <br />>ignature Phone Number_ <br />62081 <br />�. ,1 3 <br />