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LE3 <br /> Waste Tire ..ak vey & Inspection Rep(,. c Inspection Report Number ■ <br /> State of California Survey Form - Page 1 Il - 1143762 <br /> CIWMB 181(New nage) ry <br /> California Integrated Waste Management Board y <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- + OInspection Type (Fill one) <br /> Site Suffix: ` - <br /> _ - 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Say ; {� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected B <br /> P Y Inspector <br /> Physical Address Stoto <br /> I 1 <br /> S} r✓� o� (, 5 5ao(� Inspection Date Q / <br /> Time In Time Out <br /> Business Rep Title (� 0 AM 2 Q AM <br /> ' L PM J O 9 PM <br /> C oc� - <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 /> 1fJ 10 Active Q Passenger Q Generator Q Outdoor <br /> -- <br /> Latitude Q Closed Q Altered N <br /> GPS 0 Q Hauler Q Indoor/A <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned 10 OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) FO ►'t'ro <br /> Q New Tire Dealer Q Auto Repair Q 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 0 Other R-WALIACOUTIRI FkADt 1� <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 i 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 <br /> m / m <br /> 010 14 CCR§18459.1 -Tire Program ID Number from CIWMB M / <br /> 00 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 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 /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators (9 In Compliance - No Violations <br /> Q Q Other: § <br /> Comments ►�O� j(1� 1(1 �Ol� rJ�bT 0[1 1S A4e "-O 1 CAOVI d IA)CLS—fA&Id <br /> �o_Vlto�wk�d�S oS' af�u�trF r oow�)-_ - - -- - -- <br /> N o��. �. �u t✓l� uses P4(�e,_1�(1v_ es��1 �or &s1 J I AS icf <br /> TO <br /> Inspection Form Included: Q�! <br /> Comments Included: <br /> Q Bu Hess Rep's Signa ure -Phone Number ` <br /> b Inspe tis Signature J Phone Number <br /> - - -- _ <br /> INSTRUCTIONS ON BACK Correct:* incorrect: X 11 (� ? A fZ 31 <br /> 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Co :L <br />