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Waste Tire SL ey & Inspection Report Inspection Report Number <br /> CIWMB 81California <br /> 04104) SurVe Form - Paae 1 11 - 1127481 <br /> California Integrated Waste Management Board Y J <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> rBusiness Profile Inspection Details <br /> TPID- — - 1 _ © I Inspection Type (Fill one) -Site Suffix: l 40 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: San MU,1n &f4 O CHP Q CIWMB Q Complaint Q Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> smoA Tfctwspor4ief—, 3 E <br /> Physical Address 9 <br /> Moo Lcm�sr Ajc-- <br /> L&roe A J' 13D Inspection Date ' b a a <br /> Time In Time Out <br /> Business Rep Ti/tlee T I r^ 3 - <br /> Q AM O 4)AM <br /> v- v O-PM--- 1 I O PM- <br /> - Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> ' ' ® Active Q Passenger Generator Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> Q Inactive ®Truck <br /> Longitude - o Q Planned Q OTR 0 End-Use Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer Q Auto Repair Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 0 Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> 0 Service Station Q Hauler 0 Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> O O <br /> 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 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m <br /> Q 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) <br /> Q 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q 0 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 1 <br /> in Compliance - No Violations <br /> Q O Other: § AA <br /> Comments 011� <br /> . 1 <br /> Uhl cufn -- - - -- -- -— <br /> �LcStc' U� 1 (e. ,c� 4S AIN-i r lS �tee i 14L1�Cr- <br /> Inspection Form Included: Q <br /> Comments Included: Q0..silels�e'. <br /> _ - --Si nature Phone Number Inspec is Signa ure _ hone Number <br /> ----- - _ <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X+ I M , + 12 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pinkpy: E ® ■ <br />