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r / <br /> Waste Tire Sui - Jy & Inspection Report` .nspection Report Number <br /> �n .til State of CaliforniaCIWMB 181 <br /> ■ <br /> California Integrated Waste(New Manage04104)ment Board Survey Form - Page 1 Il 1141006 <br /> P-1rt A.- Survey__ - BLUE OR BLACK INK PEN <br /> iness Profile Inspection Details <br /> ,D- 1 C 1 I _ Inspection Type (Fill one) <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Localr l If Referral,choose referral type(Fill one) <br /> Identifier: San JO Ll.ln `01-0 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> 1 Inspected By Inspector <br /> Lk a- S n�e-rna�ivtnwl SIBS �n 3 h <br /> Physical Address - V <br /> cn LS to <br /> aqo 3 N w ov Off- CI� 55ab� - <br /> Inspection Date <br /> ` oe�,kor� <br /> Time In Time Out <br /> Business Rep Title M 0 AM 0 0 AM <br /> V 0 PM J 4 PM <br /> M G u�� 70�eat o Schley Proc>ti1�t �} - --- -- - - <br /> - - --- - - - - ---- -- — - -- - -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I <br /> Q Active Q Passenger Generator Outdoor <br /> O • Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive le Truck <br /> Longitude - Q Planned ® OTR Q End Use Q Container <br /> Business Type (Fill all that apply) Fo <br /> New Tire Dealer Q Auto Repair A Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Jsed 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 /> V 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 Date M / m / m <br /> 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 In Compliance - No Violations <br /> Q Q Other: § <br /> Comments t 1 1 [QST f `.17%S01% j�J�l�� (�n1�1`'—�. <br /> N oyons o taus c Q4cel n• _. <br /> ection Form Included: Q <br /> Comments Included • y <br /> ur/,,�ryy 7 op <br /> - ` '''^' --- - I0 - It0`�J� O <br /> 11 Business Rep's Signature Phone Number Inspec#o 's Signature �WSone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect. t 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />