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a Inspection Report Number <br /> Waste Tire Suh .ey & Inspection Report ■ <br /> State of California 11 - 1127474 <br /> CIWMB181(New 04104) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- 2Inspection Type (Fill one) <br /> Site Suffix: ` D J 3 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: San 4t W� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V Inspected By Inspector <br /> �pss�� �CI?ma� c <br /> Physical Address _ <br /> A lr <br /> 0 A2Lm b()lc, <br /> Inspection Date l 1 � j Q � O <br /> SA-E,C�V4\-n-) � a5 I l <br /> Time In Time Out <br /> Business Re Title F, O AM 0 AM <br /> \ p U ® PM L� PM <br /> eyl - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) � � <br /> 0 (Fill one only) � (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> • Active Q Passenger le Generator 0 Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 10 Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q 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 6u �lee'T <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> Q 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> �®In Compliance - No Violations <br /> 10 0 Other: § -- - - _ <br /> Comments <br /> 5 OY— - <br /> Inspection Form Included: Q 1 t <br /> `6Ls-- <br /> Comments Included: Q — <br /> Business Reps Signat re Phone Number Ins ct Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect:� ( VI is X A _� 2 3 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink py: ® 0 <br />