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Waste Tire SLMInspection Report Number <br /> y & Inspection Repor <br /> -- <br /> State of California <br /> California <br /> CIWMB 181(New nage S u rve Form - Page e 1 � � � I U t 3 2-9--A.-] <br /> California Integrated Waste Management Board Y J <br /> Part A- Surv� BLUE OR BLACK INK PEN <br /> .B i `.,. +ury r(yi/rub + l� s�u':::rlk"tti �`( i^.fir�, e.'u"'z'pD A x}G✓, t4 rn"'✓,�., , Y, •,„ ,'T"F';,:, 1°� " ,',�tt;'" ta" rMwt �:; <br /> us Hess P1 b <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I ,� l (� <br /> Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: <br /> 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name a' — <br /> • B <br /> Inspected Ins <br /> i 7 P Y Inspector <br /> Physical Address <br /> L <br /> Street <br /> _ Inspection DateEE <br /> FT-1 <br /> City State fIP Cade Time In <br /> Time <br /> eOut <br /> Business Rep Title <br /> 0 AM <br /> Q AM <br /> Q PM <br /> r1-1 i1 0 <br /> PM <br /> Operational <br /> Status 1-ire Type Business Role <br /> (Fill one only) (Fill all that apply) (Fill all that apply) ( i1 <br /> (joActive 0 Passenger 0 Generator (� <br /> Latitude . O <br /> ��� 0 Closed 0 ,Altered " <br /> Hauler <br /> D 0 Inactive 0 Truck <br /> Longitude 0 End-Use 0 Container <br /> .,._ ,G a„., � ,n,.: ,..P . <; I ��•,� ,.,, .„ ; 0 Planned 0 OTR <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 0 Other <br /> - <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> 0 A HAULING AND MANIFEST REQUIREMENTS <br /> ---- — --- - 0 Notice Of Violation 0 Extension <br /> 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 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire 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 1 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0In Compliance - No Violations <br /> 0 0 Other: § -----------_.-------- -- ------ ---- <br /> Comments ) t Jf J <br /> ('is L.-l -__; .�,` ( •. _ I J i�{:r `� ("i';Lt �' i � �' t <br /> -- ------ ----_-.. ------ - <br /> Inspection Form.Included „ "'� r' 6 4�✓'9 Yd ' +i"'ri rf i�idti v( i t+�� Irl + y'Y ei�Y --- <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X "v ep , 62081 <br /> ■ <br /> C t <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® S <br />