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nsis2oq.o22s <br /> Inspection Report Number <br /> Waste Tire Survey & Inspection- Report <br /> State B 181 forma Survey Form - Page 1 I 1 - 1108425 <br /> CNVMB 181(New 04104) g <br /> California Integrated Waste Management Board "�J' <br /> Part A- Survey BLUE OR.BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I - Inspection Type (Fill one) <br /> x:Site SuffiI I 6 10--HI ® Routine Q Re-inspection Q Referral Observation <br /> Local _ � If Referral,choose referral type(Fill one <br /> ) <br /> Identifier: I � w_MQCHP QCIWMB QCom Complaint <br /> Q Educational Visit Q Other <br /> Business or Facility Name t <br /> Inspected By Inspector <br /> I <br /> Physical Address I I iloll <br /> L 1](T, —b�_, <br /> 51-tree1-100 — - - <br /> /� V Inspection Date <br /> L_/.T. am. - - --R�o_ �l �l <br /> Cify c �� St3tJ ZIP Cods Time In Time Out <br /> Business Rep Title 00 AMAM <br /> I <br /> ® PM I —I I . Ivi 5; ® PM <br /> _Pe-fie. <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> O ®Active Q Passenger ®Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> 0 Q Inactive ®Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ®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 /> I —J <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A 1H.MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q 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 Bea Ii <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <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 for NOV or DC7) <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/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> Q 1 Q Other: § — ­ <br /> Comments C <br /> 1 <br /> Inspection Form :ncluded: O - i <br /> ncluded: Q <br /> Comments Kusin ep's Si tura Phone Number Inspe or Signa r Phone Number <br /> 19 62081 <br /> .INSTRUCTIONS ON BACK Cor ect: ncorrect: XI AJAJ P LIE1 111,2131 ® ■ <br /> White Cop CIWM Yellow Copy:Operator Pink Copy:LEA. <br />