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® Waste Tire ..ul .ey & Inspection Rej.. _ rt Inspection Report Number <br /> cias <br /> ='1 State of California 11 - 1140829 <br /> CIWMB 181( e ) Survey Form - Page 1 <br /> California Integrated WasttManagement <br /> Waste Management Board <br /> -t A- Survey- -. _ BLUE OR BLACK INK PEN <br /> lness Profile Inspection Details <br /> .elD- Inspection Type (Fill one) <br /> Site Suffix: ' 5 __7 Lj ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: San ���(� � L 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address l 1t73Y�X? <br /> Inspection Date t C)TQ 06 S <br /> Time In Time Out <br /> Business Rep Titlef AM l I ® AM <br /> ' �l 0 P l ( ` 0 P <br /> ----- <br /> - Operational Status Tire Type j 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 /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> CAPS Latitude 0 Hauler ® Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude — 0 Planned ® 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 0 Dismantler 0 Tire Derived Fuel <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 ® Other fl C6(fiu_'� <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> �V I A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42 - 0 Notice Of Violation 0 Extension <br /> 951 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 <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / M <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 (Required for NOV or EXT) <br /> 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: § <br /> Comments <br /> .pection Form Included: 0 <br /> Comments Included: <br /> usiness ep's Signature — — Phone Number ct r' Signature Phone Number <br /> INSTRUCTIONS ON BACK [Correct:* Incorrect ( 62081 <br /> _ - - - <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■. <br />