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@ Waste Tire Su <br /> NI & Inspection Report Inspection Report Number <br /> State of California <br /> No <br /> a <br /> CIWMB <br /> ew 04/04) <br /> California Integrated T Waste Management Board Survey Form - Page 1 i 1 1140671 <br /> Part A- Survey - - BLUE OR BLACK INK PEN <br /> i Business Profile Inspection Details <br /> TPID- I Inspection Type (Fill one) <br /> Site Suffix: 44 Y a * Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �0 A�&rN 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected B <br /> P y Inspector <br /> Physical Addre <br /> 3LIGd I / -- <br /> NcA51 e t` (�c! • - -— <br /> c1 S3� Inspection Date G 3 f <br /> rc u t CtA y <br /> Time In Time Out <br /> Business Rep TitleO AM 0 AM <br /> ✓ v ® PM Z o� U ® PM <br /> IV1Ion - - <br /> (Fillonal only) <br /> rage Type <br /> (Fill ireType at apply) (Fill all that apply) (Fillallall that apply) <br /> Tire Count (Whole/RTE) I 7 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> Latitude O 0 Closed 0 Altered 0 0 <br /> GPS Hauler Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> - <br /> Business Type (Fill all that-apply) <br /> - — -- - -- -- - - - - - - <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 9 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> i -- <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> --- -- - - - -- - -- 0 Notice Of Violation 0 Extension <br /> 0 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 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred I CIWMB Enforcement <br /> 0 0 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 <br /> in Compliance - No Violations <br /> 0 0 Other: <br /> Comments <br /> _ �avk, i nC�C� c am- f c2 CY�so� OL- J G_�Ct 2, <br /> fu ((u vl�►� W C" ►mac, <br /> - N o—_til ;o_�4��C�S_ � C��r-�S � C_csv►C..��dam-• � - - <br /> Inspection Form Included: 0 <br /> Comments Included: <br /> Hess Rep's Signature Phone Number spector's Signature Phone Number <br /> - -- - - _ <br /> 9 M4 62081 <br /> INSTRUCTIONS ON BACK Coct xXVC <br /> l <br /> White Copy:CIWMB Yellow Copy:Operator Pin <br />