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s' • �:�i:-i�!!I/�{4Gflffild+"ii-'a � r:::_•::-.s ter.:-: -..-. ._-_ ,. ,_ r:.S r ...-.._____' .,.....<.._s�____ ..... ......... _ <br /> ■ y & Inspection Repoft-' Inspection Report Number ■ <br /> ��•= Waste ��_,�re ���. <br /> State of California r' t� <br /> CIWMB 181(New 04104) Survey Form - Page I I' m 10 7 4 8 <br /> California Integrated Waste Management Board <br /> Part A-Survey_ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ® � � - o t Inspection Type (Fill one) <br /> �Site Suffix: ` ( 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local � If Referral,choose referral type(Fill one) <br /> Identifier: <br /> San J O �n lJ�o Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> CC4s 4 �&Wqus� Se-i�1 (,LS <br /> Physical Address 1i l l� �en ECORO <br /> Inspection Date a Q <br /> L ® J Time In Time Out <br /> Business Rep Title U O AM I , O AM <br /> 1 ` i PM a b PM <br /> c� <br /> - - Operational Status Tire Type Business Role Storage Type <br /> Q <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> •Active ® Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Truck <br /> Longitude - Q Planned S OTR 0 End-Use - ® Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q 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 Other <br /> - ----------- <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V ' A HAULING AND MANIFEST REQUIREMENTS <br /> - Q Notice Of Violation Q Extension <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements DateM / m / m <br /> Q ® 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> Q Q <br /> 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days i <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q ® 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> Q 1 Q 1 Other: § _],�•�( - --- -- — — <br /> Comments (� �U1 �i )`t S� lk �4j�O5 rn��� t'1 „c' <br /> `►1 �J1: <br /> Inspection Form Included: Q �ure <br /> /,(�_Comments Included: -- - �1f0 ���Business Rep's SPhone Number Inspect 's Signature Phone Number <br /> --- <br /> -- - - -- - 62081 <br /> INSTRUCTIONS ON BACK ! Correct:* Incorrect: X �� �� EjX Ai, '° 1 2 3 <br /> ■ arta -_ - prat_ ® ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink 6KA <br />