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Waste Tire b6fy & Inspection Repo ,Inspection Report Number <br /> ■ State of California 1 1 - 1088300 <br /> a <br /> CIWMB 181(New 04104) Survey Form - Page 1 <br /> California Integrated Waste Management Board ------ <br /> Part A-_Survey_-_ - BLUE OR BLACK INK PEN <br /> Business:Profilea, Inspection Details <br /> — — - -- <br />} TPID 1 Inspection Type (Fill one) <br /> Site Suffix: ��_ O 9 �� �ijj ® Routine Q Re-inspection Q Referral Q Observation <br /> Local _i_ If Referral,choose referral type(Fill one) <br /> Identifier: San Toaqu)n C,Our) 1 <br /> Q CHP Q CIWMB Q Complaint Q Educational VIsiY Q Other <br /> Business or Facility Name Inspected By Inspector <br /> c�c: L ca I+r a rI M a nye+n anC,2___.__—s _ <br /> _. _.__.__._..._ Ds <br /> J <br /> Physical Address f Q ( <br /> 2005 r.r oh,n_ <br /> Street <br /> Inspection Date 0 <br /> i -TraGuGA 9 5317-1 <br /> _._. __...._ _.. __.--n--- _ <br /> City Slate zip Cods ime � Time Out <br /> Business Rep Title O AM Q O AM <br /> r Noy-on <br /> 0 PM <br /> ,�, Operational Status �� �y"/ Business Role Storage Type <br /> w (Fill one only) (Ft ' ( h� y�', (Fill all that apply) (Fill all that apply) <br /> IMM WON I NOW, gr / Active � neT"/ Generator Q Outdoor <br /> O Q Closed ltci�y „ <br /> GPS Latitude — (0 Hauler Q Indoor <br /> QInactive „f fuck <br /> Longitude — , __TT 10 <br /> I Q Planned Q OTR Q End Use Q 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 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 <br /> 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 <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / F11 <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 /> O 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 Q Other: § <br /> Comments etldn_ r ornw -kh�s (�a-�-e ire �a) C) jl SAS - <br /> d -- � -t I res s 'o_rQd- to c c n~��I r,�r ten- e <br /> D�1 arc ny►r0-0-medal �;E1-0Ce,s �TTC�lU 4F roOyyC,S - o I as we L__ <br /> I(- <br /> as Clean Harbor Eryiror,men�al -_ r )C S��t� � 151'� 03q -a � or <br /> //;�'"r ;4vr��i`.".,„", i"•o-•""l .,ro %,j.; it, � r�,3r�'wy � h 4" n, r G d pan w� r ,,.,h,- ;w, <br /> Inspection Form'lncluded Qi " <br /> Comments Included: 'Y <br /> .* ��. S ri ,„�u e , Phone Number <br /> Business Rep's Signature Phone Num►ae_r <br /> INSTRUCTIONS ON BACK Correct: Incorrect: (r4 <br /> I I 11 1' 11 62081 <br /> eWhite Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA �� <br />