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il-waste Tire Survey & Inspection Repoi Inspection Report NumberState of California Il - 1140798 <br /> CIWMB181 <br /> Waste <br /> eManag) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> r'- q A- Survey_ - BLUE OR BLACK INK PEN <br /> iness Profile Inspection Details <br /> ..,ID- +-� r, 1 _ rn 1 Inspection Type (Fill one) <br /> Site Suffix: ` ` I `'� V le Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: San do ap 1, CVA nk Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> nA <br /> Physical Addi <br /> 1 <br /> ?ork cAL>L7 YD r1 CJt�ftSst��,N <br /> Inspection Date <br /> CA <br /> Time In Time Out <br /> Business Rep TitleO AM O AM <br /> a 3 0 PM 0 0 PM <br /> -- - - - Operational Status Tire Type Business Role Storage Type j <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> Q Active Q Passenger Q Generator Q Outdoor I <br /> O •Closed Q Altered � <br /> GPS Latitude NI Q Haule lh Q Indoor <br /> O Q Inactive Q Truck A <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 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 <br /> Q Q Q Notice Of Violation Q Extension <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 /> 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 EXT) <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 �f 1 I t <br /> T n-t�'\ 11 <br /> ,section Form Included: QIP ���_� <br /> Comments Included: Q — -- — <br /> Business Rep's Signature Phone Number Inspe or's Signature _ _ Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: I e }� ,� PLIE1 III <br /> 62081 <br /> ■ ` White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />