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Waste Tire Su. _ ey & Inspection Report Inspection Report Number ■ <br /> alifornia <br /> State <br /> IW tedWa(Waste <br /> eManag) Survey Form - Page 1 12 - 1 0 7 9 4 4 8 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection_ I Inspection Type (Fill one) <br /> Site Suffix: a Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: San loGtf W o ((n.Xn � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ` Inspected By Inspector <br /> y'Aen 0 n TcLu�'-n 3 _ b I <br /> Physical Address �C, (ORD <br /> Vkkk G �mmAve, , <br /> (' �j Inspection Date <br /> S�'b `� O� Time In Time Out <br /> Business Re �dcu L� Title I o - � C �AM � e� � I@ AM <br /> - 0 P J 0 P <br /> J011� LIl'uL �lrrri nwl �. <br /> Operational Status Tire.Type 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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> 0 Closed Q Alter�dNIA <br /> Latitude Q Hauler oorGPS 'V d �A <br /> Longitude 0Q Inactive Q Truck�n <br /> Q End Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® 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 Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> FV q 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 i Date <br /> M / m / m <br /> Q Q 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 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 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 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> ® In Compliance - No Violations <br /> Q Q Other: § <br /> Comments n \ '[ Z[ 11S �L2•�__ C7�1 .1Jy� ] GG—�.Q(L� �� 1 <br /> No nscsA- <br /> IN <br /> h�•, I. Fuc' ' nus ne Aftb I(Mloll --0l - cto- ." is �0 - <br /> Inspection Form Included: QI <br /> Comments Included: Ql� <br /> Business Rep's Signature Phone Number Inspec 's Signature one Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: t ( 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink py: ® 0 <br />