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Waste Tire Su )y & Inspection Report Inspection Report Number <br /> Slate California I 1 - 1140764 <br /> CIWMBB 181( eSurvey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey _ BLUE OR BLACK INK PEN <br /> j Business Profile Inspection Details <br /> � TPID- Inspection� © � 0 � Inspection Type (Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: � 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name - - <br /> Inspected By Inspector <br /> IDU Rio PGS -L-vtG. <br /> Physical Address - /� �h:` �✓` '"t%tw <br /> 3;F S- <br /> a � C) 6 / / <br /> rv�.:�� GA gs�o e. Inspection Date / <br /> Time In Time Out <br /> Business Rep Title O AMO AM <br /> J <br /> / I / �y S ® PM 1 D 41111 PM <br /> am;/YLi V r dl cl 10 60 -- <br /> - -- - -- - - — Operational StatusTire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ` O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �j 0 Active 0 Passenger ® Generator ® Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> 0 0 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 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 /> V A 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 Date <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 j (Required for NOV or EXT) <br /> 0 0 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years .77777171, <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 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 /> Inspection Form Included: 0 <br /> OG Z <br /> Comments Included: ® - -- -- - ------ -- -- - - --- - <br /> B ess R%' <br /> 's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS O B Correct:9 Incorrect: X � E"X Al L 1 2 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Cot y:L 41 <br />