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Ins ection Report R�..tuber <br /> NUVA <br /> WasteTire Su�y & Inspection RepoMd�- p p 1°°State of California <br /> Surve Form - Pa e 1 I1 - 1086965 <br /> CIWMB 181(New 04/04) Y <br /> California Integrated Waste Management Board --- - <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- v _ Inspection Type (Fill one) <br /> Site SuffixC ® Routine oRe-inspection oReferral 0Observatl£bn <br /> LocalC If Referral,choose referral type(Fill one) <br /> Identifier: t t C t- 1 �.t I Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical AddressJl ' iC <br /> � � I <br /> Stmt r--_ Inspection Date <br /> City state ZIF'�"ade Time In Time Out <br /> Business Rep Title tt OAM �`" O AM <br /> 0 PMF � _ m O PM <br /> 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 /> Active Q Passenger Q Generator Q Outdoor <br /> Latitude ,�O 0 0 <br /> { Closed Altered <br /> GPS 1 —� 0 Hauler Q Indoor <br /> C Q Inactive Q Truck <br /> Longitude — ; Q Planned o OTR Q End Use Q Container <br /> Business Type (Fill all that apply) " <br /> Q New Tire Dealer Q 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 1@ Other <br /> Part B - Inspection of Waste Tire Dealer, Generator Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V i AULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 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 0 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 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> Q 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> 0 O ---- - - --- <br /> Other: § <br /> Comments <br /> 1 <br /> fl <br /> 1: <br /> Inspection Form Included, <br /> � J �/'� <br /> l.� � � ° t r ,7(';,a. ✓a'',Pr }"" �� �[��` ' pComments Include ( p. 4f g/ustress a Phone Number [inspectlr's SI nat Rhine Number <br /> - De <br /> �:3� <br /> INSTRUCTIONS ON BACK" Correct:* Incorrect: �,, P 1D g I 62081 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />