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: Waste Tire Survey & Inspection Report Inspection Report Number <br /> t7-T State of California T 1 <br /> California Integrated tWase81 eManagement Board Survey Form - Page 1 I i 1088465 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- r7 _ I Inspection Type (Fill one) <br /> Site Suffix: ` t © 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local1 If Referral,choose referral type(Fill one) <br /> Identifier: san JV���n �lll Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> VX <br /> \��\,�� Inspected By Inspector <br /> & �^ <br /> Physical dress <br /> 1, sc Q <br /> g533�j Inspection Date S 07 <br /> Time In Time Out <br /> Business Rep TiCtlei 0 AM <br /> '-} '3T � AM I 3 � 0 PM <br /> o,(, V � PM <br /> � of QX�an <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 13 <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 0 Active Q Passenger 46 Generator Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hainer Q Indoor <br /> O Q Inactive 0 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 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 /> 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 Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date 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 EXn <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 �� �IS G �i 1� 0i GO <br /> QS �-r Cin l a, Oc15 � � ClJn <br /> fU��\1 � u, S N�(,Dv��,t'e. a�t�-�1uJgu0�i1Ve Cts— ,�f U)4Ae,�teve, �tr, <br /> Inspection Form Included: Q Q r• � ,-� n��/�7 �� S`-'"-1 - <br /> Comments Included: Q 9 <br /> l <br /> Business Rep's Signature <br /> Phone Number Inspe Pr's nat <br /> Sigure Phone Number <br /> INSTRUCTIONS ON BACK Co e - Incorrect-X ry, ,/ E;X A M P j LIEI 2 2 3 szoal <br /> White Copy: IW MB Yellow Copy:Operator Pink Copy:LEA <br />