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M119 Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of Ca <br /> CIWMB 1811'(New 04/04) SurveForm - ParyMe 1 I 1 - 1143538 <br /> y <br /> California Integrated Waste Management Board ! �+ <br /> - BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> Business Profile Inspection Details <br /> TPID- _ <br /> Inspection Type (Fill one) <br /> Site Suffix: O S a , 4D Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: San Q CHP Q CIW_MB Q Complaint Q Educational Visit Q_Other <br /> BusinessorFacilityName <br /> Inspected By Inspector <br /> (' b2f� /Ac� � �51os� - <br /> Physical Address � <br /> - <br /> C Inspection Date <br /> 0 d V Time In Time Out <br /> Business Rep Title ( 0 AM r� 0 AM <br /> 0 PM <br /> Juru nnany <br /> ,�1 d LJ �. - - - -- <br /> ---- ----- - --- - - Operational Status I Tire Type FBusiness Role Storage Type <br /> 5 (Fill one only) (Fill all that apply)' (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) Cp <br /> Active * Passenger 6 Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer le Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used <br /> ed Tire Dealer Q Auto Body ! Car Dealer Q Collection Q Crumb Rubber <br /> Service Station Q 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 HAULING 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 I <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date M / 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 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/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 Q Other: § 1 1 — <br /> Comments �1y�(l0,,1 ---- <br /> Inspection Form Included: QI .! IF <br /> Comments r/ /` -�!' <br /> Comments Included: <br /> Business Rep' gnature Phone Number Inspe is Signature _ Phone Number <br /> - - 62081 <br /> INSTRUCTIONS ON BACK orrect:0 Incorrect: X A P � � , 2 3 <br /> ■ t <br /> White Copy:CIWMB Yellow Copy:Operator Pink Co :L <br />