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ce <br />Waste Tire Survey & Inspection Report Inspection Report Number ■ <br />rr $tateof B181rOrnla Survey Form - Page 1 1 8 -1 01 0 6 7 3 <br />CIWMB 181 (New 04(84) <br />California Integrated Waste Management Board <br />Part A - S u rvey <br />BLUE OR BLACK INK PEN <br />Inspection Details <br />Inspection Type (Fill one) <br />Business Profile <br />TPID -r n a - 0 Y <br />Site Suffix: I % I <br />® Routine 0 Re -inspection 0 Referral 0 Observation <br />If Referral, choose referral type (Fill one) <br />Local <br />Identifier: s(.GxI cmti- <br />Wf <br />/\ _ <br />0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br />Business or Facility Name <br />V P L Trawspoc-t <br />Inspected By Inspector <br />Physical Address <br />3 I 0 �n" (� )—✓�S <br />Lodi q 5a q0 <br />Inspection Date 0 <br />t <br />Time In Time Out <br />Businesss, Rep Title <br />0 AM 0 AM <br />PLWP7& <br />O PM O PM <br />operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Count. (Whole/PTE) <br />(Fill <br />(Fin one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />r <br />® Active <br />0 Closed <br />0 Passenger <br />0 Altered <br />®.Generator <br />0 Hauler <br />0 Outdoor <br />0 Indoor <br />GPS Latitude <br />O <br />0 Inactive <br />0 Truck <br />Longitude - <br />0 Planned <br />0 OTR <br />0 End -Use <br />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, <br />Z <br />0 0 PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 0 PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 0 PRC § 42956 - Registration/Decal in Vehicle m <br />0 0 14 CCR § 18459 - Responsible Entitles Complying with Manifesting Requirements <br />0 0 14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />0 0 14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />0 0 14 CCR § 15459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years a <br />0 0 14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />t <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 <br />0 1 0 1 Other: § <br />I <br />Comments '�oil r.s 16 flow i wa's h •2Gt ` iS TZZL4 VZ <br />W611 WOW . rte or WiNdWi t fDv- Atd- • f lye r&4r4?d im 6 &sn 64. rvlayii & syieu.►�1 <br />R2�c�in n.Cs�s bh Sid -Fur' 7Jl/�S,�1V2 �.eyerl�'i-6yt �yec'�✓' con�ro( <br />Wi$�es &$OA5� IrylA sk (7ictfivYlS 0/d-'4. <br />Inspection Form Included: 0 �try,,p,A /,�f� 4tn . <br />L — AR <br />';4.p.--]]] <br />Comments Included: 0����� <br />" <br />usine Sgnature Phone Number Intars rgpwr, Phone Number. <br />_ <br />0716504.0018 White Copy CIWMB Yellow Copy Operator Pink Co LEA ® ■ <br />PY <br />