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V <br /> fi4 I'i4 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California I 1 1088047 <br /> CIWM6181 Manage(Ne 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- � - Inspection Type (Fill one) <br /> Site Suffix: J 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local t If Referral,choose referral type(Fill one) <br /> Identifier: Sao Jio�v.l n au � 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Bust ess or Facil``ity��Na``mJJe Inspected By Inspector <br /> 1� k II terns ao Ati()( _ <br /> PhysicahRddress 1 3 ' O In <br /> 1 �S O CA W3 30 Inspection Date / 1 1 / O <br /> L Time In Time Out <br /> Business Rep Title 0AM 0 AM <br /> C D o PM I a � 3 e o PM <br /> Y 'tit q Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) I (Fill one only) (Fill all that apply)' (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger O Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive S 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 0 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 I A i-AULiNG AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires I 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle m <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> O 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB II II 1:11 M <br /> 10 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 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 /> i0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments - �C)05 <br /> ICXN �2b rl-Ifia� ps (1�ce.u,S <br /> Inspection Form Included: 0 G p JIone <br /> Comments Included: 0 �""� �d U 34q""Business R p' ign ure Phone Number Insp or's Signature Number <br /> / 62081 <br /> INSTRUCTIONS ON BACK Co rest: ncorrect: X V E XI A M1 P�(_ E 1 2 3 <br /> White Cop';' Iry ��;��r,u�,� Pink Copy LEA �� <br />