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Waste Tire Sup y & Inspection Report ispection Report Number <br /> Slate California I 1 1140805 <br /> CIWMB 181( e ) Survey Form - Page 1 <br /> California Integrated WasttManagement <br /> Waste Management Board <br /> Part A-- S urvey BLUE OR BLACK INK PEN <br /> (Business Profile Inspection Details <br /> TPID- `, G _ 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: wL 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Na. Inspected By Inspector <br /> Physical Address <br /> Inspection Date <br /> CA ��,3�C7 <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> d Q D (P PM '? ® PM <br /> -- -- - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active 0 Passenger ® Generator 0 Outdoor <br /> 0 ! 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive ® Truck I <br /> Longitude - 0 End-Use 0 Container <br /> 0 Planned 0 OTR <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair ® 0 Trucking Fleet 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 I 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 /> / <br /> 0 0 i 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements �� Date m / m <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 (Required for NOV or EXT) <br /> 0 i 0 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <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 <br /> in Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> Inspection Form Included: 0 <br /> Comments Included: ® - - - - - - -- - --- <br /> Business Rep's Signature Phone Number Inspector's Signatur Phone Number ; <br /> 62081 <br /> INSTRUCTIONS ON BACK orre � In �rr �t' , �. 1 2 3 <br /> ��. <br /> White Copy:CIWMB Yellow Copy:Operator Pink Cop L <br />