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Waste Tire �. & Inspection Repo44spection Report Number <br /> FBfl State of California — EJB <br /> CIWMB 18ast(New Manage) Survey Form - Page 1 I1 1127871 <br /> California Integrated Waste Management Board <br /> Part A- Survey - BLUE OR BLACK INK PEN <br /> - --- - <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: $ S Z <br /> i ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: cSCL*1 V_ cwl" 0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name J U <br /> SLC <br /> Inspected By Inspector <br /> a3- - 1 . <br /> Physic _ <br /> liYt i aUCa' i c <br /> Inspection Date C) <br /> Time In Time Out <br /> Bust ss Rep <vv�alll j p,► — - [7 <br /> •AM <br /> ill <br /> S QPM 0 P <br /> K <br /> _ <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 /> 0 Active ® Passenger • Generator i Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude I Q Hauler ® Indoor <br /> O ' Q Inactive ® Truck <br /> Longitude — O Planned O OTR O End-Use 1 Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair •Trucking Fleet Q Government Q Retreader O 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 Notice Of Violation Q Extension <br /> O 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 O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 . 0 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 O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred f CIWMB Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators S In Compliance - No Violations <br /> 1010 1 Other: § <br /> Comments <br /> Inspection Form Included: O J <br /> Comments Included: 0 <br /> Busine ep's • nature one Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect X V ;E X I A' p 112 <br /> - - <br /> White Copy:CIWMB Yellow Copy:Operator Pink <br />