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*cee_ Waste Tire Su*ey & Inspection Repordh Inspection Report Number <br /> 6eTi State of California T 108806^ A O^� <br /> Cgrated 1 teManage) Survey Form - Page 1 11 8 Vu {6 1/ <br /> California Integrated Waste Management Board <br /> Part A- Survey' BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ` ^ � Is <br /> t 1j, <br /> Inspection Type (Fill one) <br /> ffiSite Sux: S I l ®Routine Q Re-inspection Q Referral Q Observation <br /> Local G� \ If Referral,choose referral type(Fill one) <br /> Identifier: .�An ��( ��� W � Q CNP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> ioS- I _ 1hyal A dress ® J , L6—E.SAD--j <br /> Stre� / / O (� <br /> I �AA O Inspection Date '11 <br /> City l(`Jf1]ifateZfP Code lode Time In Time Out_ <br /> Business Rep Title ��� 46 AM I - 1 Q AM <br /> t \Jjo PMPM_0� <br /> Operational Status Tire Type Business Role Storage Type <br /> t (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) t t 1{ <br /> Active Q Passenger * Generator A Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> - —-- -- Q Inactive Is Truck <br /> Longitude - I i Q End-Use 0 Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Trucking Fleet Q 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 <br /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 <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 FXT) <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 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 /> Q 1 Q 1 Other: § ',,Q <br /> CommentsC_� �1/1�1 �y�—- -er� <br /> �yJ 5 <br /> U a i_vi\s-Of C�Ce.�5-4 Cl�nn <br /> No�C�:—1 lre� e�S olc,r _tin o�.c�- - �► <br /> Inspection Form Included: Q 1-R K <br /> Comments Included: ?`�GS�S(Z — - — — — Lm- 3 I�" <br /> Business Rep's Signature Phone Number Inspe ors Signature Phone Number <br /> INSTRUCTIONS ON BACK Co rec : Incorrect: XA I'rl P L 1 z 3 62081 <br /> White Cop CIW Yellow Copy:Operator Pink Copy:LEA <br />