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Waste Tire 1-;liLji „ey & Inspection RepG1 c Inspection Report Number ■ <br /> State of California I 1 - 1143813 <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 Detaiis <br /> TPID- i Inspection Type (Fill one) <br /> Site Suffix: I �q 5 ( 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local a If Referral,choose referral type(Fill one) <br /> Identifier: San QI,��(� tt,Y\ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> �3b3 � e_4 <br /> AInspection Date <br /> oL� b C 5x65 <br /> Time In Time Out <br /> Business Rep �q Title <br /> (�� }� ^ I � O AM � � Q AM <br /> PM L� SPM <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 /> 40 Active 0 Passenger 0 Generator Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude - 0 Hauler Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer ®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 0 Other <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 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 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 /> 0 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 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 ® In Compliance - No Violations <br /> 0 1 0 1 Other: § ' n <br /> Comments 1L-l�d'A _' ALiffheA Wn �11b & CI(�� 1(]��, 06U)))AA <br /> t'� <br /> �O Viol��r�arS o�' G�fe S 4� �v�Cs - <br /> Inspection Form Included: o A <br /> Comments Included: 0 — , <br /> u ness Rep's Signa re Phone Number Inspe is Signature Phone Number <br /> INSTRUCTIONS ON CK [Correct,O �Incorrect: i E A MIONLIV 111213 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy.L ® ■ <br />