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„iiii;� <br /> Waste Tire SL ay & Inspection Repor Inspection Report Number <br /> StateCIWMO181(fCalifornia Survey Form - Page 1 I Z - 1 0 7 91 0 1 <br /> CIWMB 181(New 04/04) <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: I 3 3 q -7 Z - * Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: San J-0 OCjU\0 C O An+ <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> S o we� Aita Se v\j ice, 3 g - I O l <br /> Physical Addres yw-\S- 1 aNA L"CQS <br /> 85 C N IJl a C. 1 gar D f', <br /> Inspection Date Q <br /> �rC�G�{ �'�376 v <br /> JJ Time In Time Out <br /> Business Rep Title O AM Q AM <br /> O PM O PM <br /> 'Doul Sar es m ana eC-1 V -- <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 ! Generator 0 Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - 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 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 — 0 Other -roww ( q C01V1PG1n <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility � ENFORCEMENT STAT'7Extensio <br /> - -V. A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation l <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 <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 -- --- - ------- -- - - - <br /> 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 O 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 /> O Q Other: § <br /> Comments �"' .1 J 11 `1__ <br /> - --- �j'nU.A',:hz 1Yws RecA-1 on (tl P�f _Orrrw-j �"((l1S C(Q'Te 'k "&Q OI(ri w i a� W QS 11% Ct <br /> -Appc . 'Jct,dj wasie 448-,5 on sife , FOZA,% -A nn ces VeW C_\e 7kiCE5 <br /> nn 156e All -how -1-rucVs Care sery.t edbq Cox DTS or I.,e2 SSrMwmb r srle. <br /> Inspection Form Included: (ZOQ <br /> Comments Included: <br /> Business p's Signature Phone Number I tor's Signa r Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorr, jItIXIA M P L E ! 2 <br /> -------------- <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />