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Waste Tire Suit . ay & Inspection Report Il <br /> Report Number <br /> State <br /> CIWMB <br /> 181(New <br /> Survey <br /> �M/e Form Page 1 j i 114 3 8 4 0 <br /> CIWMB 181(New nage) V � Y y g <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � � _ � � Inspection Type (Fill one) <br /> Site Suffix: 13 � 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local , If Referral,choose referral type(Fill one) <br /> Identifier: �1Lj �� C� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name - - Inspected By Inspector <br /> Physical Address <br /> _ Inspection Date7 l <br /> ( Ca e 378 <br /> Time In Time Out <br /> Business Rep Title L� *AM { _ •AM <br /> ' 6 [QPM � � Ll J QPM <br /> bio►tel s, -�. . ;��sP�,�� ----- ---- -- - <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 /> 0 Active 0 Passenger ie Generator # Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 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 *Trucking Fleet 0 Government 0 Retreader 0 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 /> VA HAULING AND MANIFEST REQUIREMENTS 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 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements DateM / 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 -- ---- - -- -- <br /> 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 i <br /> ,ur <br /> AV_ <br /> Inspection Form Included: 0 C� Q <br /> Comments Included: 0 - - - (�OPlh�n%e <br /> j - 0 ``zi&S- w.�Rep's Sign ure Number Ins a or's i Pat re Phone Num_ ber <br /> - - - <br /> ___B - <br /> INSTRUCTIONS ON BACK Correct:f♦ Incorrect V \� �/� E , , p 1 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy: A ® ■ <br />