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Waste Tire Su. ,�ey & Inspection Repoi _ Inspection Report Number ■ <br /> State of California <br /> CIWMB 181(New 04104) Survey Form - Page 1 I 1 - 1144041 <br /> California Integrated Waste Management Board <br /> - BLUE OR BLACK INK PEN <br /> A-Survey_ <br /> Hess Profile <br /> Inspection Details <br /> I r-ID- ^ Inspection Type (Fill one) <br /> Site Suffix: ` J 5 �C ® ' Routine Q Re-inspection Q Referral Q Observation <br /> LocalL If Referral,choose referral type(Fill one) <br /> Identifier: �6tvh e0�' 'j Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected <br /> L _ Inspected By Inspector <br /> Pcal Addfess— !-f 0,\L �T i'I'rC�I�� <br /> Inspection Date 5 i 0 <br /> G� g5Aa5 <br /> Time In Time Out <br /> Business Rep Title � � O � �PM �AM <br /> � � <br /> • PM <br /> - -- - - - — OperationalStatus Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> 0 1& Closed Q Altered <br /> GPS Latitude Q Hauler / Q indoorn <br /> 0 Q Inactive Q Truck k/IN % /VIA <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Rusiness Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> FO Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> - - -- - - <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A j HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 M / M / m <br /> Q Q 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q 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 I&In Compliance - No Violations <br /> Q Q Other: § - <br /> Comments jn.5 �1T/1 e{n1c�c7t' � '1 t� C �/ 'c;» �s"ll3 C C� <br /> J3 CX625'ye_s& 3aa6 4eavl.ce 0-, 7A 121115olz c):1l"bc ely 'c- cx <br /> ,gspection Form Included: Q <br /> Comments Included: Q - —- - - <br /> Business Rep' Signature Phone Number I is ure _ Phone Number <br /> - - y��� 62081 <br /> INSTRUCTIONS ON BACK LCor Ao Incorrect: X "1 e X +� L 1 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />