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Waste Tire S y & Inspection Repo Inspection Report Number <br /> ■ RM`111M State of California CIWMB 181(New 04/04) Survey Form - Page 1 I1 114— 14 <br /> California Integrated Waste Management Board <br /> Part A- Survey - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- `7 � _ � Inspection Type (Fill one) <br /> �Site Suffix: v1 l ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: San J6 (ZUA 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> 9_ax,�cy,) G 6 5,.�e-E TCw'�I <br /> Physical Address E� <br /> Lt�b 6 , W40)01 c, Sk <br /> C G Inspection Date <br /> nkc'�' CA �5Time In Time Out <br /> Business Rep 1 Title I � � 0 AM � � D : PIM <br /> % Min 696r)s4E vW(LV� PM <br /> - - - Operational Status Tire Type Business RoleStorage Type <br /> Tire Count (Whole/PTE) C; c� (Fill one only) (Fill all that apply)' (Fill all that apply) (Fill all that apply) <br /> J d 0 Active Passenger ® Generator Is Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive � Truck � , <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair I*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 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V AI NG Waste <br /> AND MANIFEST REQUIREMENTS <br /> Registration Transport of Tires 0 Notice Of Violation 0 Extension <br /> 0O PRC§ <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 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/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> I ' <br /> 00 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments1 <br /> ' d ildl <br /> fou ,n�. w�4G �-,rte, io%AA <br /> - <br /> No ViolAtlof1S 6S acus cyncQrn� <br /> Inspection Form Included: DI 7' y <br /> a1" 7A <br /> Comments Included: & r1 <br /> Business Rep' Signa ure '4 ne Number lnspe is Signature Phone Number <br /> L - — <br /> INSTRUCTIONS ON BACK Correct: Incorrect (�{ �,�ly pMel 11 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />