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103S60S0020 <br /> ■ .. Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California +t D ►r <br /> r cgrate,s,skew nage Survey Form - Page 1 1 4 • <br /> California Integrated waste Management board - <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business profile Inspection Details <br /> TPID- I's <br /> � — [�N] <br /> Inspection Type (Fill ones <br /> Site Suffix: ' ILLL� J <br /> Routine 0 Re-inspection 0 Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 'San J(Dm tt rl (otA11 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> f Inspected By Inspector <br /> Physical Address F] F_ <br /> Street �C n� t � � � � • <br /> 7rt Inspection Date, 1 I I 3 <br /> i e Code <br /> Time In <br /> City tarZIP Time Out MOO Business Rep Title ,�.AM PM [:::N ' 0 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 /> lb Active Passenger Generator *.outdoor - <br /> 0 ClosedAltered <br /> Latitude ! I 1 <br /> GPS � Q Hauler 0 indoor' <br /> 0 Inactive 0-Truck <br /> Longitude 0 Planned, 0 OTR 0 End-Use 0•Container <br /> _ <br /> Business Type {Fill all that apply]• <br /> New Tire Deater Q.Auto Repair •0 Trucking Fleet. 0-Government Q Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0-Collection 0 Crumb Rubber• <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other I 1 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler.and-End-Use Facility ENF�t]RCEMEN7 ST�Q�TiIiS <br /> V A HAULING ANQ MANIFEST REG2UIREMENTS '.: y ; <br /> t� Notice t7fF Violation ,Ex a <br /> 0 0 <br /> PRC§42951-Waste Tire Hauler Registration and Transport-of Tires w <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. `Compliance Deadline <br /> Q 0 PRC§42956-Registration/Decal in Vehicle <br /> i7 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements• Date � <br /> 1 1 0 gl � 2 <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 [Re4+�lred for Nps or EXT) <br /> is 0 14 CCR§18459.3-Retention of Comprehensive-Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Referred1 CIWRAB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities „..... <br /> " <br /> 0 0 14 CCR§18462-Manifest.System Requirements for Tire Dealers or Waste Tire Generators `Q In Compliaf a t�❑ Violations <br /> 0 0 Other: <br /> Comments ❑,��1���,s�`L�s�,i�_l!'3�:nr��r_'�t��rnc.l� b sl+���C.c ct_G,Yl�— ._._..__._ <br /> .�Col� � tea-usnLACA - <br /> e� <br /> Inspection.Form Included: Q l � <br /> Comments Included: 1- �� `A7 <br /> i - ` =� = <br /> Business Rep' Ig�4hae Phone Number- Insp es Signature •P-.hone l+Fumber. <br /> { fi2081 <br /> INSTRUCTIONS ON-BACK C rre Incon t— l Y ){ A ..P L E f 3 <br /> ■ White Cop CIW Yellow Copy:Operator~ Pink Copy:•LEA. ® ■ <br />