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Mj] Waste Tire Suk .ey & Inspection Report Inspection Report Number ■ <br /> State CIWMB California I 1 114 0 7 7 6 <br /> grated Waste <br /> eManag) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A-- Survey_ __ _- BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I � � � 1 � � _ � � Inspection Type (Fill one) <br /> Site Suffix: ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �- ) If Referral,choose referral type(Fill one) <br /> Identifier: San J 0G.��,lf1 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> C6 uh.- C 0l� <br /> Physical Address <br /> Inspection Date I <br /> S1 Time In Time Out <br /> Business Rep Title <br /> I� . 150O AO AM. <br /> 3 3 P!(AWn LA) <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 /> •Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered 44 <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive • Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair • 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 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility ENFORCEMENT STATUS <br /> V IA HAULING AND MANIFEST REQUIREMENTS <br /> 0 A PR - 0 Notice Of Violation 0 Extension <br /> C§42951 Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. I Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 1 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 O <br /> 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/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities j <br /> 014 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> LO Other: § <br /> Comments In t�j"% —i /_ e <br /> 17 <br /> Inspection Form Included: Qli <br /> Comments Included: <br /> Business Rep's Signature Phone Number insp s Signature Phone Number <br /> - -- - 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X (� X A 1 ; 3 <br /> ■ - --- © ■ <br /> White Copy:CIWMB Yellow Copy:Operatorr Pink COV <br /> o y: <br />