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_ Q9i8204'�399 <br /> i= Waste Tire Survey & Inspection Report Inspection Report Number <br /> _ <br /> State of California <br /> ' CIWMB1B1(New04104) Survey Form Page 1 I 1 10 7 9 3 3 1 <br /> California Integrated Waste Management Board <br /> Part A- SurveyBLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type.(Fill one) <br /> Site Suffix: DLO /l)TS 3 I <br /> ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �ay� a _ �� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name [[0 Inspected By Inspector <br /> IC_ <br /> Physical Address J t <br /> �3 3 y Oil AoAt— <br /> Street , O <br /> 0A- 9508 I Inspection I I � � C <br /> City State ZIP Code Time I TltntOut <br /> Business Rep Title OA <br /> / M O PM <br /> AM <br /> D_O d ire► t�l c7`0 TO ck. �I — <br /> - =/} -— O rat _ Tire Type Bu ' ss <br /> 'Role torage Type <br /> Tire Count (Whole/PTE) I j �j (Fill (Fill all that apply) (Fill all t y) (Fill all that apply) <br /> f t a ®Active ® Passenger ® Generator le Outdoor <br /> i I IO Q Closed Q Altered <br /> Latitude. <br /> GPS I I I _� Q Hauler Q Indoor <br /> _F�O <br /> Q Inactive Q Truck <br /> Longitude Q Planned Q OTR Q End-UseQ Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet ® 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 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other I I <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q otiee Of V olatlo Q xtens on <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. C-ompliance ad ine <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days Required forNOV 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 1 G�IWMB Enforcement <br /> Q O 14 CCR§18461 - Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> Q Q 1 Other: § �f�, . ,./ yJ p <br /> Comments /,�j, <br /> �s 6o�dev,�}_ ols _r—,_1 a- c�ir�_o��s—(Jos D7s <br /> J3{� p_'em,e _ revzt,s <br /> NO �i_�1_0ji <br /> Inspection Form Included: Q (/ / �'J <br /> Comments Included: �i Q�—�L�—�{�`� q��` <br /> usiness Rep's Signa ure Phone Number Inspector' Signature Phone Number <br /> INSTRUCTIONS ON BACK Corr • . I correct: E X a �h P L Z 2 3 62081 <br /> ■ White Copy 11N Yellow Copy Operator Pink Copy LEA <br />