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-M = Waste Tire Survey & Inspection Report inspection Report Number <br /> 11il State of California 11 - 1140568 <br /> COMB 181(New 04104) Survey Form - Page 1 <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> A- Survey -- <br /> Inspection Detail-s <br /> .iness Profile <br /> TPID- nspection Type (Fill one) <br /> X: S <br /> Site Suffix: Observation <br /> Routine 0 Re-inspection 0 Referral 0 Obseation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: San 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Businesq.,or Facility Name Inspected By Inspector <br /> Ma_c qcel <br /> Physical'Address t 0 Es�.A6 <br /> 103 � ��.� ��5��� .n �-�� �I. a3 � --- -- -- <br /> Inspection Date 03 0 <br /> 4 Time In Time Out <br /> Business Rep Title OAM 0 AM <br /> PM PM <br /> C (A Business Role Storage Type <br /> . - �6 1�\ 00p4" Operational Status Tire Type (Fill all that apply) <br /> Tire Count(Whole/PTE) 'Fill one only) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger 0 GeNrator 0 Outdo <br /> 0 0 Closed 0 Alter I <br /> 0 1 0 Hauler GPS Latitude V 0 Ing <br /> 0 0 inactive 0 Truck VA <br /> Longitude 0 Planned 0 OTR 0 End-Use 0 Container <br /> siness Type (Fill all that apply) <br /> New Tire Dealer 0 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 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> 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 1 PRC§42956-Registration/Decal in Vehicle <br /> I <br /> 0 0 114 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB 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 I 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 (0 in compliance No Violations <br /> 0 0 Other: § <br /> Comments <br /> cc Ix <br /> U-V <br /> w—n <br /> Inspection Form Included: 0, � (�U,' f—IVU�� /'b, <br /> e z <br /> Comments Included: I* <br /> Buliess Rep's Signature Phone Number Inspecto(js Signature Plfone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* incorrect: �=XA M p, I <br /> MWhite Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA M <br />