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n Re o"Inspection Report Number <br /> Waste Tire Su y & Inspection p � <br /> >, <br /> State o181(California Surve Form - Page 1 <br /> CIWMB 181(New 04/D4) y g I 1 - 1140738 <br /> California Integrated Waste Management Board <br /> Part A-Survey _ _-- BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- L � j\ � C O l � !,� � Inspection Type (Fill one) <br /> Site Suffix: )® Routine Q Re-inspection Q Referral ON <br /> Local �,, If Referral,choose referral type(Fill one) <br /> Identifier: San 3 �U�U)n cwfn \ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facili Name Inspected By Inspector <br /> loo- <br /> Physical Address J 1 O I &o <br /> I OcAlAwn Ave- <br /> C� <br /> _ Inspection Dateon qs�o <br /> Time In Time Out <br /> Business Rep Title AM O AM <br /> ' 5 O PM S Q PM <br /> - --- --- ---- -- --— —- - - --- - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) r-� C O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> J ® Active Q Passenger ® Generator ® Outdoor <br /> GPS Latitude D Q Closed Q Altered <br /> ® Hauler Q Indoor <br /> D Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q 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 /> * Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station ® 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 THAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q 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 /> QQ 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date F11 / 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 10 Other: § ) <br /> Comments <br /> Inspection Form Included: <br /> n r II <br /> Comments Include 'z d ! 3 Z-g_�� �--}- 0107)N��' l7f <br /> usln ig ure Phone Number Inspe t is SignatureL hone Number <br /> �' 62081 <br /> INSTRUCTIONS ON BACK j Correct: Incorrect \� � X <br /> Pink CoVLWhite Copy:CIWMBYellow Copy:Operator <br />