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t l€ Waste Tire 80ey & Inspection Repaft Inspection Report Number <br /> State of California Survey Form - Page 1 I 1 - 1127488 <br /> CIWMB 181(New 04104) <br /> California Integrated Waste Management Board <br /> 'art A-7 Survey-_- BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> - nsPoeTyPa (Fill one) <br /> Site Suffix ® RoutQ <br /> Re-inspection QReferral QObservation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 'San `-10Ckq(M Co un <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility <br /> PhyName Inspected By Inspector <br /> 7 <br /> Cal <br /> A� <br /> siA dress <br /> 36 7 cL)- z-o u e <br /> Mar � � Inspection Date <br /> Time In I l Time Out v <br /> Business Rep Title <br /> • ® AM Z QAM <br /> �iYlo Lal'nsr,� �� Q PM ( .� ®PM <br /> C��� --- - <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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> — - - - -- - - O ® 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 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,_ T1 S ,�q <br /> AULING°AND MANIFEST'REQUIREMENTS, � :fir <br /> QIn <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Extension <br /> Q PRC§42953-Contracts with Registered Waste Tire Haulers. [compliance Dead <br /> Q Q PRC§42956-Registration/Decal in Vehicle ' <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> IQ 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 <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 <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 <br /> Q Q Other: § <br /> Comments - <br /> Inspection Form Included: Q CSGG <br /> Comments Included: Q - -- - - - - --- /'l - - - -4ec .r'sffigature .B sSignature PhoneNumber I s Phone Number <br /> -- <br /> INSTRUCTIONS ON BACK ` 1 62081 <br /> �+ � I r` I �� 1 E I I I I <br /> White Copy: IW Yellow Copy:Operator Pink Copy:LEA <br />