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08080040030 <br /> Waste Tire Survey & Inspection Report Inspection Report umberState . <br /> CNVM 181(California Survey Form - Pagel Ir I�8 1 0 7 9 4 7 $ <br /> CIWMB 181 Waste <br /> Y <br /> Callfomia Integrated Waste Management Boats <br /> Part A.Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- —:1t/ Inspection Type (Fill one) <br /> Site Suffix: 1-3 161013 I 7 ®Routine 0 Re-inspection Q Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 5 O CHP O CIWMB Q Complaint O Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> t-d_ <br /> Physical AAddress 551 - l' Q <br /> Istreei 3'zi_Spaze"�`'` l�vc 1 <br /> p Inspection Date <br /> State ZIP Code Time In Time Out <br /> Cify <br /> Business Rep Title O AM O AM <br /> Al n :MOPM ' 'F '* <br /> PM <br /> ---- <br /> I Operational Status Tire Type Business Role Storage Type. <br /> .Tire Count(Whole/PTE) <br /> (Fill one only). (Fill all that apply). (Fill all that apply) (Fill all that apply) <br /> � � � I� I a <br /> 0 Active 9 Passenger ®Generator Q Outdoor <br /> � 0 Closed Q Altered <br /> GPS Latitude -- I I Q Hauler Q Indoor <br /> —I• ---�— �---`--I O Inactive Q Truck <br /> Longitude - I- I - I planned Q OTR End-Use Q Container <br /> Business Type (Fill all that apply) 111 <br /> Q New Tire Dealer O Auto Repair O Trucking Fleet Q Government 0 Retreader 0 Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body ®Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station. Q Hauler Q 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 /> 0 Notice Of Violation Q Extension <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q 0 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 for NOV or EXT) <br /> O ® - - <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q 0 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 /> Other. § <br /> Comments <br /> s�aao9s_•--�edz.�,,..._-.zL2-1.,B-f��ii��l�>•`e� �.,.�r �rh t�.-f e� 3 fir.ar r <br /> o ,40oG -,L ��C�/y c 6 i2 <br /> Inspection Forth Included:Q WJ4I <br /> Xa <br /> Comments Included:Q— - � 6 L3 <br /> Business Rep's ignature Phone Number nspectoes Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: 62081 <br /> (� �j EXAMPLE 1 ;23 <br /> ■ While Copy.CIWMB Yellow Copy.Operator Pink Copy:LEA ■ <br />