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Waste Tire Survey & Inspection Report inspection Report Number ■ <br /> ;. State of California I 1 - 1143560 <br /> CIWMB181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A-Survey _ BLUE OR BLACK INKPEN <br /> Business Profile Inspection Details <br /> TPID- y � � ( � � � � � � Inspection Type (Fill one) <br /> Site Suffix: I IQ • Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: San J bU.Vw�r) C�)Un� 0 CHP 0 CIWMB- 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name l <br /> ( inspected By Inspector <br /> S G n - r <br /> Physical Address 3 l I ,n ES Ao <br /> al5 w . - <br /> ^ <br /> Sive��kc�n A 5503 Inspection Date 5 V 3 / 0 <br /> f� Time In Time Out <br /> Business Rep Title n S 0 AM O AM <br /> / a J Q PM O O 46 PM <br /> Tire Type Business Role <br /> - - -- - - - - Operational Status j Storage Type <br /> 3 <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 9 Active 0 Passenger 0 Generator I&Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 1 <br /> 0 Hauler 0 Indoor <br /> 01 nactive 40 Truck <br /> �foLongitude - Planned OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) Fu ,17 <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 ® Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A 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 <br /> 0 0 1 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 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 /> 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 0 In Compliance - No Violations <br /> 0 0 (Other: § <br /> Comments �U�kk nl,, `I n6 -' G cA -V)�W +U1 \ <br /> l <br /> 11 z, 0�6- 1-��`1 - ,nr ----�jls��o . <br /> Inspection Form Included: <br /> Comments Included: t, — -- H 165- 6 b� <br /> B siness_Rep's Signature Phone Number Insp or's Signature <br /> -- Phone Number <br /> - -- - <br /> — <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X + ( 1 L 62081 <br /> ■ White _:. <br /> Copy:CIWMB Yellow Copy:Operator Pink Copy: E <br />