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Waste Tire Su► - Jy & Inspection Report ,.Inspection Report Number <br /> StateofCalifornia 181(New I 1 - 1143645 <br /> California Integrated Waste Management Board Survey Form - Page 1 <br /> Part A-Survey --- __-- _ - -- -_--- _ - - - - —- -- - --—- - - - ---BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: l —� 1 g © ! 0 Routine Q Re-inspection Q Referral Q Observation <br /> LocalI n If Referral,choose referral type(Fill one) <br /> Identifier: `� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> (�► 0 - s ) <br /> Physical dress l j L"so /Te bulc <br /> leo ` 'Io 7 m At- Avc- <br /> L /// ��I ►►�����,��` "l <br /> ilan Com Inspection Date 3 o 1 <br /> Time In Time Out 6 <br /> Business Rep Title ®AM *AM <br /> 4 IlUTI �� / 0 ' O PM l / C/ O PM <br /> t )--- - - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) n (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I ®Active ® Passenger ® Generator 46 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business 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 /> 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 i ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 ® In Compliance - No Violations <br /> 010 Other: § <br /> Comments m &kRz� f ek2cm � til. <br /> Vb6;,k--z—rns c,-Y- A-ye�3 q�- <br /> (Inspection Form Included: QI <br /> �!� LIEi `167 <br /> Comments Included: I- - - - - - - - LZ <br /> - -- - <br /> Bu Hess Rep's Signature Phone Number I t Signature Phone Number j <br /> INSTRUCTIONS ON BACK Correct Incorrect tX1 ' ; V l ? 41 I 1 1 2� 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:L ® ■ <br />