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Waste Tire u(" & Inspection Report iiispection Report Number ■ <br /> ■ 'i111 State of California11 - 112 7 4 6 3 <br /> CIWMB 181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> PartA-- Survey. _ -- BLACK <br /> - - --- <br /> Business Profile Inspection Details <br /> TPID- ` Inspection Type (Fill one) <br /> Site Suffix: 1 O I 4@ Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: San 30 ktln Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> ,_Zpjx�5 Asti G-4z_r9 - l 1 E <br /> Physical Address V SCD <br /> Inspection Date 1 � � � y <br /> Time In Time Out <br /> Business Rep Title 1 ® ISAMO PM I G 0 AM <br /> 1 J QPM <br /> �Vhn_ fA_ d b 1 t— - ---- - - Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) , <br /> O Active Passenger Generator Q Outdoor <br /> - - 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> p Q Inactive Q Truck <br /> Q End-Use Q Container <br /> Longitude - Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> New Tire Dealer 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 /> — - -- <br /> Part B -Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> %jj A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation 0 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 <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <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 Q14 CCR§18460 Q Referred f CIWMB Enforcement <br /> .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 In Compliance - No Violations <br /> Q Q Other: § 11 <br /> Comments \ I f 0. <br /> CV - <br /> Inspection Form Included: Qr7 9- <br /> Comments Included: ---- -- <br /> — - - <br /> Bus ess Rep's SI nature Ph a Number--- <br /> L <br /> Inspec is Signature — __ Phone Number— <br /> L - -- - - -- -P g —_ - _ - - 62081 <br /> INSTRUCTIONS ON BA K Correct:* Incorrect: X !,"Pi <br /> A � � f ` ` 3 <br /> White Copy:CIWMB Yellow Copy:Operator k op . ® ■ <br /> ■ <br />