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aF3F <br /> Waste Tire Sully & Inspection Report Inspection Report Number <br /> gas:- State of California <br /> CIWMB 181( e ) Survey Form - Page 1 I 1 - 1140622 <br /> California Integrated WasttManagement <br /> Waste Management Board <br /> PartA- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- S - / Inspection Type (Fill one) <br /> Site Suffix: / y 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: � Inspected By Inspector <br /> �10 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name If^ <br /> Physical Addressru lJ �s - <br /> f o f (o inl l sv,1, W c� - - - <br /> J Inspection Date 1 a <br /> Time In Time Out <br /> Business Rep Title / 0 AM O AM <br /> f 0 O PM / 0 ® PM <br /> _ pit jLc4A_k- -- I Operational <br /> oneonly) (FII <br /> l al Status I I a at a YPBusiness that Role So9thata Type <br /> Tire Count(Whole/PTE) f f 3 (FppI y) (Fillall apply) <br /> (FillalppI y) <br /> 0 Active 0 Passenger 0 Generator ® Outdoor <br /> D 0 Closed 0 Altered j <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 00 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 0 Trucking Fleet 0 Government 0 Retreader a 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 /> V7 A 11 HAULING AND MANIFEST REQUIREMENTS 11 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 I 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 /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> VW <br /> Inspection Form Included: 01 <br /> Comments Included: ® -- - - __ _- ___- -_ - Zn C _i/b$---4 <br /> Business s na ure Phone N ber Inspector's Signatu oneNumber <br /> - - -- - - --- - -o <br /> 62081 <br /> INSTRUCTIONS ON BACK Corr ct' Incorrect: X i `:X A' P 1: 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Co :L <br />