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:..:.::..:..... ... -_.:-. --- ......................... <br /> _ <br /> I = Waste Tire Survey & Inspection Report Inspection Report"umber <br /> =o <br /> State of California Il - 1140604 <br /> CIWMB181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> A-Survey-- - - - -- - - - - - - - <br /> Hess Profile Inspection Details <br /> TPID- ` r Inspection Type (Fill one) <br /> Site Suffix: 1 Ip $ O O All Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �(�� J Uu �tt n �V�n - 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> 1 _ - <br /> Business or Facility Name Inspected By Inspector <br /> K�, WCs� 3 - 0 &n E&woo <br /> Physical Addr s <br /> 10 bss 5 _ 11A cmc I ar r� CLC1- - <br /> Inspection Date ( �1 � a � � 1 <br /> ]t{l�� C�Y.(�� CA sa31 Time In `J Time Out l <br /> Business Rep Title LQ 10 AM 1 10 AM <br /> I 0 ` 0 P 1 � � QPM <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 /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> Closed 0 Altered J4 <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> " siness Type (Fill all that apply) — <br /> Vew Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> U Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 I <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 (Required for NOV or EXT) <br /> 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <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/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 In Compliance - No Violations <br /> 0 0 Other: §� --- <br /> Comments <br /> v1��r���vnsU -� <br /> Inspection Form Included: 0 <br /> Comments Included: ` -- - - (�o�ll��3 <br /> Business Rep's Signature Phone Number Inspe is Signature Phone Number <br /> - -- - <br /> - - - - - - - /_- 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: �% V P l� f <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />