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09259050052 <br /> Waste Tire Survey_& Inspection Report Inspection Report Number <br /> HAA_ <br /> AA State of California .- <br /> AAA CM/MB tg1egSurvey Form - Page 1 Il - 1086958 <br /> California Integrated WaststManagement <br /> Waste Managee ment Board � <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection.Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 1 Q Routine •Re-inspection Q Referral Q Observation <br /> Local ,f� - If Referral,choose referral type(Fill one) <br /> Identifier: San ,� """n�1' l Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> .,� ` <br /> Business or Facility Name V <br /> Inspected B <br /> T� r� ••�, p Y ) Inspector <br /> Physical Address <br /> OH5:=t t <br /> Street p�r_�_P.osc,� <br /> Inspection Date <br /> 10 <br /> L S�LkCc` �5atZ5�Uco <br /> L_i?� <br /> City otate L!N e Time In Time Out <br /> Business Rep Title O AM F I AM <br /> I I� ® PM —�J �� 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) i (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f ' ®Active Q Passenger ®Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler ® indoor <br /> O Q Inactive Q Truck <br /> Longitude – Q Planned Q OTRQ End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ®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 Q Other I I <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFO CEMENTS ATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q Notice Of 1/iolation Q Extension <br /> 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 /> QQ 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements 7 <br /> Date 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 Q 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/C-IWMB 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 1 Other: § <br /> Comments <br /> Inspection Form Included: <br /> Comments Included: Q �— <br /> Business Rep's ' nature Phone Number Inspe or's ign ture Phone'Number <br /> 62081 <br /> INSTRUCTIONS ON BACK OE <br /> M, n¢orrect: X A M P 1 2 3 <br /> WhiteYellow Copy:Operator Pink Copy.LEA <br />