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.-._• ---- --.. - --_. -_.... .........._____:_. ......, <br /> 1 � <br /> ?; * Inspection Report Number <br /> Waste Tire Survey & Inspection Report � <br /> -���- State of California <br /> CIWMB 181(New 04/04) Survey Form - Page 1 11 - 1143989 <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> � A- Survey------ - --- . <br /> Hess Profile I Inspection Details <br /> - -- - - <br /> TPID- 2 Inspection Type (Fill one) <br /> Site Suffix: �2 J Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: � �/� �( �� L ►�, Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Businessor Facility Name Inspected By Inspector <br /> -fs l A t6sr bJ <br /> Physica�Address, <br /> 90 't 63cl—�—M Gam' <br /> �pp Inspection Date <br /> �t1� "� - � Time In Time Out <br /> Business Rep Title 0 AM/ I <br /> 0 AM <br /> O PM 6 q� ® PM <br /> ---------_- Operational Status 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 ® Closed Q Altered 1 A11;j /V//A <br /> PS Latitude Ji/A Q Hauler Q Indoor <br /> G <br /> D Q Inactive Q Truck <br /> Longitude - Q Planned I Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q <br /> to 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 L <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 9 Others rU�C�1' �Cr/► J <br /> ------- ---- ---- <br /> Part B -Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A 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. i 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 <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> Q Q <br /> 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <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 ® In Compliance - No Violations <br /> 0 , 0 Other: § <br /> Commentsf'1T7zns en --- <br /> -L -L��( ' ►- -moi l r +3 r r �n ✓--- efe�fi f- `fly��jszcc ter. <br /> — <br /> ��. ►nem <br /> Inspection Form Included: Q <br /> Comments Included: 8• <br /> Ql11 Business Rep's Signature Phone Number 1 p tors Ig ure Phone Number <br /> - - <br /> - — - ---- -- - 62081 <br /> INSTRUCTIONS ON BACK Correct. incorrect ; L <br /> ■ <br /> ■ <br /> White Copy:CIWMB Yellow Copy:Operator J Pink Copy:LEA ® <br />