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■ = Waste Tire Sur ;y & Inspection Report inspection Report �,,.,urnber ■ <br /> State of California <br /> 3 CIWMB 181(New x Survey Form - Page 1 Il - 1127490 <br /> Californiaalifornia 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: ` 01 6 q 1� - ®Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �� /� �� If Referral,choose referral type(Fill one) <br /> Identifier: San �d t Y CGU l�9_ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> L'o v'f-Ac;,� � �11 n 5C K S f C��l��� Cj <br /> Physical Address <br /> c23 a3 Lo vC ctc,C_ )k�-) <br /> Inspection Date 1 1 / 5) / <br /> cev� �� Cep '?� l l <br /> Time In Time Out <br /> Business Rep Title 1 hAM AM <br /> `� l � ' () V OPM l 1 ' a —7 0P <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) r <br /> Q-1 <br /> (Fill one only) (Fill all that apply)` (Fill all that apply) (Fill all that apply) <br /> Active ® Passenger 0 Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0) Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 4&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 ® Othern� +/ <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. 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 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 /> 0 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 IV in Compliance - No Violations <br /> 0 0 Other: § <br /> Comments f <br /> 1�O��(1 C'� 1�'L�.'�-2F"�Z,Z� Lc�,7C� <br /> - <br /> 1), <br /> or <br /> Inspection Form Included: 0 f <br /> Comments Included: 0 -- — �-�77 9/0) <br /> O! -- l��—��✓� <br /> Business Rep's ature Phone Number In e is igt re Phone Number. <br /> INSTRUCTIONS ON BACK Coe correct: ( (I X)MI P I L IC 1112131 62081 <br /> White Cop tr <br /> Yellow Copy:Operator Pink Copy:LEA <br />