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08234050021 ■ <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State C`wM 181Califrna Survey Form - Pa e 1 I1 1088141 <br /> CM'Me 181(Na.( nage Y <br /> California Integrated Waste Management Board <br /> Part A-Survey' BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- - O Inspection Type (Fill one) { <br /> Site Suffix: ' :312-1 y Z 9 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: San —Tbet9utn C.o ur'y Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name e Inspected By Inspector <br /> I— YA o vv IJ° C ctl&rrm l ct I 3 - 171071 <br /> Physical LkcaS <br /> Address � <br /> �_123y. V✓• Cl�QY+er ll,�4y I <br /> Street J <br /> Inspection Date <br /> _Stacictvn CA 952.06j <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title O AM O AM <br /> Gln Srt' -G1na 177-' Q PMu —i O PM <br /> in 'Par{-s.Couc�te.r_� ` <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) -(Fill all that appy) (Fill all that apply), (Fill alLthat.apply) <br /> 0 Active Q Passenger 0 Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude � � i Q Hauler Q Indoor <br /> -- — - .'- - — - Q Inactive Q Truck <br /> Longitude - I I ` Q Planned OTR Q 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 Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 0 Other Tr?'Eq ulpf»er$—Re- n}eta—A41es)$vC <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> _.............--...- <br /> 131WAMHAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> O 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 /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> O Q 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or DC7) <br /> Q 0 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 I 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 1 tQ 1 Other: § <br /> Comments <br /> Rau � i+c�±�t�ttan—�te,c�urrned—t�tis_d.at�� -}� �ollotil ir1�w�—poked <br /> F ct1� 1rr�stzs 2 dl ec4t^I� <br /> 51 on <br /> r �lol e�r Cctl� orni f_�L n <br /> ►y�,s_��h Yl cem r i al H a�d�i��D Iv L3:►_on_:c f'cT R en tQ l Oiv_is_i_or►use <br /> _W_►�.s_Qr1 v1n �r�e,�oe va�s�,�.re.f�,ov_a1 � �ack�t� -r+re_serJ►_ce.� <br /> Inspection Form Included:Q (/', . ((J� _ /� (Zaq <br /> Comments Included: vl� � Y68-3 <br /> Business Reps g ature Phone Number I ectors Signatu Phone Number <br /> INSTRUCTIONS ON BACK tGo'rreC Incorrect: X A M� P L E 1 2 3 62081 <br /> ■ White Yellow Copy Operator Pink Copy.LFA ® ■ <br />