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Waste Tire ;llIu, - Jy & Inspection Rep.,,"t %Inspection Report Number ■ <br /> =i= Stateof CaliforniaCIWM181 I 1w 04/04) - 1143962 <br /> California Integrated WaseeManagementBoard Survey Form - Page 1 <br /> BLUE OR BLACK INK PEN <br /> Business Profiley _ - - - - -- — Inspection Details <br /> i TPID- O _ � I Inspection Type (Fill one) <br /> Site Suffix: e d 1� 7 ® Routine Q Re-inspection 0 Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: tl � ��n �un O CHP Q CIWMB O Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> l <br /> U�l &V qx� S�t� ,f7CtCj 1.t 1 c� � _ � � I <br /> Physical Address \ t <br /> Inspection Date <br /> J�o Cin `�J 1 <br /> Time In Time Out <br /> Business Rep Title O AM r' O AM <br /> n 1 � <br /> PM " ® PM <br /> - -- ------ - - - - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> • Active • Passenger 40 Generator ® Outdoor <br /> O 0Closed 0Altered I <br /> GPS Latitude O Hauler Q Indoor <br /> O O Inactive Truck <br /> Longitude - O Planned Q OTR O End-Use Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer O Auto Repair ® Trucking Fleet Q Government O Retreader Q Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body Q Car Dealer Q Collection O Crumb Rubber <br /> Q Service Station Q Hauler 0 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 /> O Notice Of Violation O Extension <br /> O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 O i PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / Ffl <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers j O Referred/CIWMB Enforcement <br /> 0 O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 ® 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators . In Compliance - No Violations <br /> 0 O Other: § <br /> Comments n 1 <br /> 1C.11�.bt1r)0_ 0 _ _an L _ s <br /> t - cl._ uu �,C,�- `�u`4 I (AVc-_ ►lc '�1u_lctlb�r_ b f <br /> Sc.S uk rAQ4ma\_ Rhus Iniki l-r) less <br /> Inspection Form Included: Q <�J<�`�r�" <br /> Comments Included: `�`� - - DO U� ) <br /> Bu Hess Rep's Signature Phone Number InRspe or's Signa re Phone Number <br /> - - - — — <br /> INSTRUCTIONS ON BACK Correct Incorrect N� E XIA a P E 1 2 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Co L A <br />