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WasteInspection Report Number <br /> Tire Sy & Inspection Repor <br /> &'tt State of California ", ;'1 -� <br /> CIWMB 181 New 04/04) Survey Form - Page 1 aj E '� <br /> California Integrated Waste Management Board ' <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- _ - Inspection Type (Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local C If Referral,choose referral type(Fill one) <br /> Identifier: San �OQ l.� (1 <,0ua+t 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> J <br /> Physical Address ) 1 <br /> I n C. �nr� �,�- I <br /> Street <br /> Inspection Date �� <br /> "10 <br /> r,i` U I C )rate 'r ZIP Cod Time In Time Out <br /> Business Rep TitleI II O AM EE <br /> O AM <br /> Ljhkak W ' �OPM ' I OPM <br /> T 7- p - - <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active 0 Passenger 0 Generator 0 Outdoor <br /> GPS Latitude FT 0 0 Closed 0 Altered— -- 0 0 Hauler 0 Indoor <br /> O Truck <br /> 7� Inactive <br /> Longitude - I 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <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 I_[`/�C tar G ils.. c_ __;;��epa Lfs..I <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 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 /> 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 I CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 1 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments r _ 1 a( . (f <br /> n <br /> �­e c_ T1tt'_.-��1_C�U� 4� i( G± - ci C .,t 1 cl } +I r.e- <br /> Inspection Form Included: 0' <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X E X A M[r I L I Ej 1112 3I 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />