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:EssWaste Tire Su :y & Inspection Repo Inspection Report Number <br /> kl"&. CnNMB 181(New Survey Form -- Page 1 <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: 3 3 ,� . - O 0 Routine 0 Re-inspection 0-Referral 0 Observation <br /> Local. If Referral,choose referral type(Fill one) <br /> Identifier: Va IZ_Zzw'.l l 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> 7�1 24W <br /> Physical Address 3 9 - O I <br /> 3,2.2-3 APs 4,., <br /> Street <br /> Inspection Date <br /> d�641� %47!� X5,.2/0,2 <br /> City State ZIP Code Time In Time Out <br /> Business Rep TitleILE <br /> � 5 O PM Z;� <br /> : � Q AM <br /> ® 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 /> Tire Count(Whole/PTE) . t I <br /> I / 0 Active 0 Passenger 0 Generator • Outdoor <br /> 1 O 0 Closed 0 Altered <br /> GPS Latitude W - 0 Hauler 0 Indoor <br /> O O Inactive 0 Truck <br /> Longitude - FA] -I J 1A 1 1 0 Planned 0 OTR O End-Use 0 Container <br /> Business Type (Fill-all that apply) <br /> New Tire Dealer 0 Auto Repair 0 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 O Hauler 0 Agriculture O Shredder 0 Other I I <br /> Part B Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORGEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of lfiolation 0 Extension <br /> 0 O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 O 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 /> O 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 /> O 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance - No 1/i5lations <br /> 0 0 1 Other: § <br /> Comments <br /> e <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> B smess Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS BACK Corr t: I correct: ; 62081 <br /> XRMP :1 E 1 2 3 <br /> White 77 <br /> IWM Yellow Copy:Operator Pink Copy:LEA . <br />