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0$18404�LU1 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> rr Stateo181(Ne(Naw w"04)04) Survey <br /> C,WMB 181 Form - Page 1 1 3 1 0 7 9 2 7 5-1califomla Integrated Waste Management Board <br /> Part A-Survev BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type.(Fillone) <br /> Site Suffix: / Ll I 9 1 01 9J IO -inspection ObservationQRoutine Q Re <br /> Local /' If Referral,choose referral type(Fill one) <br /> Identltler: N 0-7,9. 1i Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> I I w r•lfoU/' - ���� S I Inspected By Inspector <br /> Physical Address / Q I Pte/ 114W-0S,11 <br /> Street <br /> CA- p53 3Inspection Date (/ <br /> L—��}_NT�G.CL J <br /> City tats ZI Code Time In Time out <br /> Business Rep Title / O AM 1 0 AM <br /> t �� (�' f3/�F��.�LT- I �CS7C_ — •� �— O PM � �--! '� � QPM <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 /> Active Passenger 0 Generator 9 Outdoor <br /> Latitude ! 0 Q Closed Q Altered <br /> GPS j Q Hauler Q indoor <br /> Q Inactive 0 Truck <br /> Longitude - i I I I 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 O 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 Agriculture Q Shredder Q Other I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 / m <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 forNOVorEXT) <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 Q Referred t 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 /> Comments7�N <br /> Inspection Form Included:Qi 2�`Rl <br /> Comments Included:Q Business Rep's Signature Phone Number Inspector's p noh a R-uMber�_ <br /> 62081 <br /> INSTRUCTIONS ON BACK C rrect. correct: (( E x a P L E 2 2 3 <br /> ■ White Co :CIWM Yellow Copy Operator Pink Copy LFA <br />