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Waste Tire Survey & Inspection Report Inspection Report Number . <br /> Stale of California <br /> CIWMB„i1(Now Survey Form - Page 1 1 8 - 1 0 0 8 0 0 2 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> 'Business Profile Inspection Details <br /> TPID- O Q .� - © Inspection Type (Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Is Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: O CHP ®CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By inspector <br /> ang �' R I�i. C ctrsfn..�{-ice,,fir+c <br /> Physical Address <br /> Inspection Date / / <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> C <br /> I `-s f O PM O PM <br /> S S JCt Id /© `rlZ1.• <br /> 5 ,Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active *Passenger Q Generator Q Outdoor O 0 Closed Q Altered <br /> GPS Latitude � Hauler Q Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station I*Hauler 0 Agriculture Q Shredder Q Other <br /> I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT,STATI$.- <br /> V A I HAULING AND MANIFEST REQUIREMENTS Notice Of Violation <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires Q Q *XtepNi�tri <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 - Responsible Entities Complying with Manifesting Requirements Date <br /> O O <br /> 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Requfrdtt)rl�vvAr. k7J <br /> O O 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Reterrefi 1 C�INM171f�1e�(IfltDx;. <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w M <br /> O O 1 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators J <br /> �'1tt ttcSlhplfltil �J¢;�Ci31��'�i11;'i-� <br /> O O Other: § <br /> Comments C-6 vxf. a LikA f l�lb(E 'tom i el1xC+i 0^ . <br /> ! ►"tnc.� (nHti. FY.c�iti-1f''rh'l�f�•-- L� �Gi,�t�5 � CrOIGt/lf/►7"y k j�S !n^q'^;��STS <br /> trJv.si+e-, Dt�+,.%e.O, �Irf(i/rV3 tJLI� rw-S <br /> G%-06z>0 Ghj cl,AJA - Ing u le, l -�1D�- 4-o <br /> Inspection Form Included: Q <br /> Comments Included: Q 4� b <br /> Bus Hess ep's n ture Phone Number <br /> 41pecto's gn ure Phone Number <br /> INSTRUCTIONS ON BACK Co root: ncorrect: } ( Zvi E X A M p LL� tL62x61 <br /> _ . .. :Op <br /> White Cop :CIWMe Yellow Copy:Operator Pink Copy:LEA <br />