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Utz, aste Tire Survey & Inspection Report inspection Report Number <br /> , <br /> State of California <br /> B 181 04/04) <br /> I 1 - 1140703 <br /> California ine grat dWasteeManagementBoard Survey Form - Page 1 <br /> Part A-Survey__-______ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ( (� 1 inspection Type (Fill one) <br /> Site Suffix: ` L d 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local �- 1 If Referral,choose referral type(Fill one) <br /> Identifier: S(�n JC J\ C17iM Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - <br /> 1,, \ / 1� Inspected By Inspector <br /> Ce, C.U 1 i t1� �t�CVLA'A' Fv Co,-(N 9 t�CI�J <br /> Physical Address �l <br /> GASZLA2 Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM /� O AM <br /> ' O * PM v V PM <br /> � - Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> ® Active Q Passenger ® Generator ®Outdoor <br /> Latitude <br /> O Q Closed Q Altered <br /> GPS Q Hauler Q Indoor <br /> O Q Inactive e 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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 /> D 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 Other: § <br /> ;omments <br /> ----�_O�i�_1.���-W�_��C.t1e-rJ_IS__��__C..bS�_Cc,I_n• - <br /> :tion Form Included: Q p <br /> :omments Included: ® lv�(-- �- 0 <br /> B ss s Signa ure Phone Number Inspr71—"-­------ <br /> Ct. ignature Phone Number <br /> — — 62081 <br /> INSTR CTIONS CK CorreIncorrect: ( 1 E X A M 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Cop :L <br />