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I, Waste Tire Sufty & Inspection Report Inspection Report Number <br />State » ClWM of California Survey Form - Page 1 i 2 -1 0 0 5 31 <br />Cgraw 1B1 (New nage Y <br />California IntegraNd Waste Management Board <br />Part A - Survey BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />TPID -Inspection ( Inspection Type (Fill one) <br />Site suffix: / 3 T - ® ® Routine 0 Re -inspection 0 Referral 0 Observation <br />Local <br />Identifier: �G1 `�QLt Cttity� <br />Business or Facility Name <br />CSI ���Y�. Co ►� t',ri-.t�� <br />Physical Address <br />s+uck_fpVl D <br />Business Rep <br />da 5011I0Aa <br />Tire Count (Whcde/PTE) <br />GPS Latitude <br />Longitude <br />Business Type (Fill all that apply) <br />0 New Tire Dealer 0 Auto Repair <br />0 used Tire Dealer Q Auto Body <br />0 Service Station 0 Hauler <br />Title <br />po"";f <br />If Referral, choose referral type (Fill one) <br />0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br />Inspected By <br />Inspector <br />0 ) ����,.�. RAZ <br />Inspection Date �} it S rl C) S <br />Time In <br />Time Out <br />Folr <br />Q AM <br />, <br />0 NOtlta Of Violation <br />Q PM <br />0 <br />Operational Status <br />Tire Type <br />Business Role <br />(Fill one only) <br />(Fill all that apply); <br />(Fill all that apply) <br />r 0 Active <br />0 Passenger <br />a Generator <br />0 0 Closed <br />0 Altered <br />0 <br />0 14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />li <br />Date <br />0 Hauler <br />O <br />Inactive <br />0 Truck <br />Q AM <br />Q PM <br />Storage Type <br />(Fill all that apply) <br />0 Outdoor,, <br />0 Indoor <br />Q Planned to OTR 0 End -Use 0 Container <br />P_ l t Ft <br />0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br />0 Car Dealer 0 Collection 0 Crumb Rubber <br />0 Agriculture 0 Shredder ® Other Cons-frkd2lbint f"laf eyl'4 Y4r <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility j..PN QA(Zk ANT STATUS <br />V: <br />A HAULINQ Np MAVIFT`EQUIRtMENT <br />0 NOtlta Of Violation <br />Q Extension <br />0 <br />0 PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 <br />0 PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Compllonce Doadline <br />0 <br />0 PRC § 42956 - Registration/Decal in Vehicle <br />m <br />m <br />0 <br />0 14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Date <br />0 <br />0 14 CCR § 16459.1 (a) (b) (c) - Tire Program ID Number from CiWMB <br />0 <br />0 14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />(Requ <br />d for NOV or EX7) <br />0 <br />0 ' 14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years <br />0 <br />0 14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q Referl'gd ( <br />1W- Mb Enforcement <br />0 <br />0 14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />r NO y)Oleldns� <br />0 <br />0 14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />0 <br />0 Other:.:._ <br />-..._..-- <br />Comments 661;4-y' QKL)r-,DC+2 S Ark 1 I P+11 Ot'-k.G'er- POI Y F7f 1 W'T S'1,0 JirP S . MQA;)Ce S�S <br />e prove d.ed On ra%,tt?S'f . k4 soo IlVe,/ ri ��, <br />^,'`S•�.P'xd 6tt.& -, liaOS arrrD,X — <br />lYKOLM4 'mire-:✓ -h"s �O.2r- ye_at'frorn S Ci 1r leo W�StfZ 4 re -5 <br />Inspection Form Included: o 0ouness <br />iv6p <br />Comments Included: Q- — ����� <br />Re s nature Phone Number In a tor's S ature Phone Number <br />I�T-.. _.� 62081 <br />INSTRUCTIONS ON BACK 4 fro ;t; ��I t ii�Ir it J ;M P i 1. El I Z 3 <br />rI. <br />.:...� t__.�_ _—��..�..-... L_.. <br />White Copy! CIWMB Yellow Copy: Operator Pink Copy: LEA <br />