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TireSui vey & Inspection Repot t, Inspection Report Numberka <br /> ] Waste <br /> CIWMB 181st State of California mage Survey Form - Page 1 Il - 1140748 <br /> California Integrated Waste Management Board J <br /> Part A- Survey_- BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � I M —7 � � r - © I Inspection Type (Fill one) <br /> U <br /> Site Suffix: IlU_ Routine QRe-ins Re-inspection <br /> -_ Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier- San -10��(,yt,�,� C�u� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name — <br /> Inspected By Inspector <br /> 764, LIJ M,%L I Il' et <br /> Physical Add ss 31� Q <br /> 307 0 3 <br /> �1 C A g537)� Inspection Date a i <br /> T <br /> r�11 <br /> Time In Time Out ` V <br /> Business Rep Title //--�� O AM O AM <br /> moo �E301rittS "I V 0 PM 3 V • PM <br /> - ��la[� - s � ��Tdirw�Of Operational Status Tire Type Business RoleStorage Type <br /> "2 <br /> Tire Count(Whole/PTE) I q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 411 Active 0 Passenger ®Generator ® Outdoor <br /> d Q A <br /> O Q Closed GPS Latitude Q Hauler Q Indoor j <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned OTR End-Use Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer 0 Collection Q Crumb Rubber r l <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other �fQ(�Sler �TIL�On <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V j A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PR §42WasteHaulerand Transport of Tires Q Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date 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 /> - ---------------- <br /> Comments <br /> � �� � <br /> - —�bU'L a- .._ <br /> �� <br /> ern. - <br /> ------_ - -- - -- <br /> Inspection Form Included: oI <br /> Comments Included: +- L/ qq 0i j -ssa- .�_ <br /> B2� n ep s Signature — Phone Number Insp tor',Signature Phone Number <br /> - - —- - -- - I <br /> INSTRUCTIONS ON BACK Correct:* Incorrect 62081 <br /> X ,� <br /> White - Yellow Copy:Operator Pinki <br /> C py:L_ <br /> ■ _ <br /> Copy:CIWMB <br /> i <br /> Pink- <br /> write copy:uivvmo -- <br />