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Waste Tire SuOW & Inspection Report ispection Report Number <br /> til State California Survey Form Page 1 1 - 1140576 <br /> CIWMBB 181(New 04104) <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: S td , r ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SLS '�pC�Gt u,+V` 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name J (� <br /> Inspected By Inspector <br /> Physical Address 1 �r - /' 0 J nn <br /> /'`�7YlGG4�L+ll! <br /> 3 3d N vli vy\ +fee-f <br /> Inspection Date Q ' <br /> CA Gl s�r�S <br /> Time In Time Out <br /> Business Rep Title z ( O AM O AM <br /> / PM D 12 S ® 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 /> 01 • Active 0 Passenger 0 Generator ® Outdoor <br /> GPS Latitude <br /> O 0 Closed 1 0 Altered <br /> 0 Hauler 0 Indoor 1, <br /> 0 0 Inactive 0 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 ® Other ie <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 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 m / 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 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 1 0 I Other: § <br /> Comments <br /> Inspection Form Included: 0 X <br /> Comments Included: -- - -- -- —04 <br /> Comments 3 <br /> Business Rep's i- ture Phone Number nspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X ;E X A IV4 P 123 <br /> White Copy:CIWMB Yellow Copy Operator Pink Co :LE <br />