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== Waste Tire Sul y & Inspection Report nspection Report Number <br /> Slate B California 1 - 1141014 <br /> CIWMB 18ast(New Manag) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A. BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- S � � � - � r Inspection Type (Fill one) <br /> Site Suffix: I %4 <br /> � � 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SGA,,,, V-11 Co Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name J -- -- -- <br /> Inspected By Inspector <br /> C, <br /> Physical Address <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title 0 AM O AM <br /> ` 0 PM � � � � 0 PM <br /> ---- '-` -- > --- 5 Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) s (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �L 9 Active Q Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPSLatitude <br /> Q Hauler Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) _ <br /> Q New Tire Dealer Q Auto Repair ® Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> --- — ----- --- -- --- - Q Notice Of Violation Q Extension <br /> Q O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q ® 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> �'h�c►.����-c�.���-r:,uaat � -{���5 c:la.�t: Ga_,c�! <br /> LAAU!� in at <br /> -- -- <br /> Inspection Form Included: Q�,J/— <br /> Comments Included: ® n ( _�ULA-OK-Z� <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> X ` t,� � L � 2131 <br /> 62081 <br /> INSTRUCTIONS ON BACK ' Correct: Incorrect: � E" <br /> White Copy:CIWMB Yellow Copy:Operator Pink Co :L <br />