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Waste Tire SL ,-,.y & Inspection Reporp p <br /> Ins ection Re o:t Number <br /> State of California — <br /> CIWMB 181(Ne ) Survey Form - Page 1 I 1 1141268 <br /> C01ffORManage <br /> lia Integrated Wasre Management Board <br /> Part A-Surve _ BLUE OR BLACK INK_ PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I 5 -1 �� �j V ( ®Routine Q Re-inspection O Referral Q Observation <br /> Local /� If Referral,choose referral type(Fill one) <br /> Identifier. C�)"� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name -( Inspected B <br /> P Y Inspector <br /> /� ;. <br /> Physical Address � � <br /> _ <br /> Lt' Ccti q ?ZC <br /> Inspection Date � / " / <br /> L`� Q <br /> Time In Time Out <br /> Business Rep Title 0 ®AM *AM <br /> r� <br /> 0P 67 OPM <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 /> f <br /> ®Active ® Passenger ® Generator ® Outdoor <br /> O 0 Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive Q 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 Q Trucking Fleet Q Government Q Retreader ® Dismantler 0 Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer 0 Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture 0 Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> vt a ]HAARD-MA AND ANIFEST REQUIREMENTS <br /> -- ----- ---- O Notice Of Violation O Extension I <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date / <br /> O Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB m 11-1 IE <br /> 0 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 /> 0 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 /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> 0 Q Other: § <br /> Comments <br /> mc <br /> Inspection Form Included: O' <br /> z� � W_s "ltd _ (, 73 <br /> Comments Included:�_ - Hess Re gnature Phone Num er IPhone Number <br /> ,-� -- �__ , 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: x E � A,! p 3 <br /> `Nhite Ccpy:CIWMB Yellow Copy.Operator Rnk Copy:LEA <br />