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�ey & Inspection Repor, Inspection Report Number <br /> ' ijWasteTireSL.. <br /> State of Californiaa CIWMB 181(New 04104) Survey Form - Page 1 i 9 - i 6 6 6 0 U <br /> California Integrated Waste Management Board �J J <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 1 t 6 1 �� V ` ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local r � \_ ' If Referral,choose referral type(Fill one) <br /> Identifier: S GLS S O�'�gyp) (�,i h l,t� ti`�/ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name UU (((( <br /> \ Inspected By Inspector <br /> Physical Address — 1 b ` - ( F `� ��c` <br /> ZD <br /> G Inspection Date l,> L <br /> Time In Time Out <br /> Business Rep Title O AM L� O AM <br /> ( '> ® PM \ ` v QPM <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) f <br /> f Active ® Passenger Generator 0 Outdoor <br /> 14 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — End-Use ® Container <br /> 0 Planned 0 OTR <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 /> ® 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 /> V A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0�PRC§42951 -Waste Tire Hauler Registration and Transperi 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 Ma-fasting Requirements Date m <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 (Required for NOV or EXT) <br /> 0 0 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> ---- - - <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 4 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> Inspection Form Included: 0 <br /> X/es <br /> �p���7t i •23�:3 yam'. <br /> Comments Included: 0 I Bure Phone Nu 11 mber Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BIncorrect: E R ,rw,� � L 1 T i 62081 <br /> White Copy:CIWMB Yellc:. --opy Operator Pink Copy:LEA <br />