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L 3 Waste Tire :My & Inspection RepA. Inspection Report Number ■ <br /> ■ "� State of California I 1 - 1143805 <br /> CIWMB181 <br /> Waste <br /> eManag) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey__ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Yj - Q Inspection Type (Fill one) <br /> Site Suffix: 1 [ 1 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local <s / If Referral,choose referral type(Fill one) <br /> Identifier: San , 10('�,C1wl(� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name l Inspected By Inspector <br /> Physicaf Address <br /> S� <br /> Inspection Date <br /> A ULM p o C A 95aao <br /> Time In Time Out <br /> Business Rep Title 0 0 O AMO AM <br /> PM �--o - PM . <br /> Operational Status Tire Type Business Role Storage Type <br /> 3 <br /> Tire Count(Whole/PTE) p (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � 5 o <br /> f f 0 Active Passenger ®Generator Outdoor <br /> i <br /> Latitude O 0 Closed 0 Altered <br /> GPS 0 Hauler Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - End-Use 0 Container <br /> 9 0 Planned 0 OTR <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 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 Other mOb,`��� ol�(r✓`IWh��I ���u� tl <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility r ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> i 0 Notice Of Violation 0 Extension <br /> �0 0 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 <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 /> 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 0 Referred/CIWMB Enforcement <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 e In Compliance - No Violations <br /> 0 0 Other: <br /> 1 <br /> Comments <br /> 4 s--on oLr n- <br /> ,Inspection Form Included: <br /> (aqq 17g <br /> Comments Included: - <br /> Businesii's Re Signature Phone Number - Inspe t s Si nature Phone Number <br /> - - - -- <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X (l'�i X A P! I ! 2 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pinkpy:L ® ■ <br />