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tIns ection Report Number <br /> Waste State of Tire Survey & Inspection Repo, c T 1P P � <br /> Integrated Wastl <br /> e04/04) <br /> California ManagementBoard Survey Form - Page 1 + 1140784 <br /> 1 A- Survey_ _ BLUE OR BLACK INK PEN <br /> siness Profile Inspection Details <br /> .'ID- � - O � Inspection Type (Fill one) <br /> Site Suffix: V Routine 0 Re-inspection 0 Referral 0 Observation <br /> Localt /��n].� If Referral,choose referral type(Fill one) <br /> Identifier: San J D (Al r) 1, 1 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> AR 51n Inspection Date l J\ 03— 1 D <br /> Time In Time Out <br /> Business Rep Title O AM 0 AM <br /> r r`f d2..\' '(�11 L9 �.�{ l�ti�aC , ✓�kTh-ttr •- -- -PM - - -- - PM <br /> ---- - - - -- ------ - - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> Latitude NV/ <br /> O * Closed 0 Alterfo/ NA NM <br /> GPS � 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0-Planned 0 OTR 0 End-Use 0 Container <br /> - g - ---- - -- - -- _� <br /> Business Type (Fill all that apply) <br /> Jew Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> Jsed Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ® 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 /> 0 i 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 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 <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 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 /> - <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement i <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 Other: § l 1 f 1 <br /> Comments '�,(,�"! 14.171cr <br /> V1 B"Ov7Zn 0 a,L__ conCin . - -- - <br /> ) ection Form Included: 0 <br /> Comments Included: �natu ��� —G��/ CJI�J'W►� � -1�-���a <br /> Busi� s ignature r Phone Number Inspec o 's Signature `Phone Number <br /> � ("� 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X it A M1IP - I I <br /> - <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />