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Waste Tire S y & Inspection Report Inspection ReportNumber <br /> Utz <br /> " State of California Il - 1140940 <br /> CIWMB 181(New 04/04) rvey Form - Page 1 <br /> California Integrated Waste Management Board <br /> PartA- Survey _ _ BLUE OR BLACK INK PEN <br /> r <br /> Business Profile Inspection Details <br /> TPID- Inspection <br /> �� _ © / Inspection Type (Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,,choose referral type(Fill one) <br /> Identifier: C ,r.� <br /> f�j Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Nam _ Inspected By Inspector <br /> Physical Address <br /> Inspection Date /7, <br /> �s33 <br /> Time In Time Out <br /> Business Rep Title r O AM _ O AM <br /> F 0 PM ® PM <br /> g4y -- - - Operational Status Tire Type Business Role : Storage Type <br /> Tire Count (Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � 1 � <br /> f ® Active ® Passenger ® Generator ® Outdoor <br /> GPS Latitude O Q Closed 0 Altered Q Hauler 0-Indoor <br /> 0 Q Inactive (®Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned ® OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet ® Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 0 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 <br /> HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> 0 0 !PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q 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 Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> (Required for NOV or EXT) <br /> Q 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 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 1� <br /> I <br /> Inspection Form Included: Q x <br /> Comments Included: ® - - - -- - p r� ) y61 06 z - <br /> Business R Signature Phone Number Inspector's Signatur Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X . E X A: P 112 3 62081 <br /> I - --- <br /> White Copy:CIWMB Yellow Copy:Operator Pink Co y:L <br />