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08206050043 <br /> en_ <br /> Waste Tire Survey $ Inspection Report_ Inspection Report Number <br /> State <br /> of C.Ieomla Survey Form - Page 1 I 5 - 10 7 9 2 9 3 <br /> CONMB 1B1(Naw 04104) <br /> Califomla Integrated Wart.Management 9.ard <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: •Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. 5CL 70a Ulf) GduQ CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected B <br /> P y Inspector <br /> I Rend T_ca►ns_(�-or�rat;on <br /> Physical Addrr� <br /> LKr►s�man Lu ecus � <br /> I-2y_I y—S_Gu XV <br /> Orn_i a St • I -- - <br /> Sheet <br /> Inspection Date <br /> ISta ck t on <br /> CA- <br /> ityStateP CoeJ Time In Time Out <br /> Business Rep Title 0 AM Q AM <br /> �_gI II _a. la.d rL-0Wra'_(_ J m m0 PM mm 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Count(Whole/PTE) �: � I ,r I �� I <br /> 0 Active Q Passenger 0 Generator Q Outdoor <br /> ' O Q Closed Q Altered <br /> GPS+ Latitude I l I, �Hauler Indoor <br /> L_1—J O Q Inactive 9 Truck <br /> I <br /> Longitude - TTTT� Q Planned Q OTR Q:End-Use Q Container <br /> _----111_J <br /> Business Type (Fill all that apply) <br /> Q New Tire.Dealer Q Auto Repair 9 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 !Hauler Q Agriculture Q Shredder Q Other I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT ST-ATUS <br /> — --._.... -------. .... . <br /> A NG ANP AN! EST REQ E E TS <br /> otice Of Yiola ion Q E.xt nslon <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 Deadli e <br /> Q Q PRC§42956-Registration/Decal Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities m m <br /> Complying with Manifesting Requirements Date / <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 (Requi ed/or NOV or EX77 <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 I CIWMB Enforcement <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> i <br /> 14 CCR§18462-Manest System Requirements or re Dealers or.Waste Tire Generators <br /> Q ifRitfTiDlIn Compliance N- Violations <br /> - <br /> Q 1 Q j Other. - <br /> Comments <br /> _�_V -- <br /> RC2ut�he..--l�s�ct►-ori— Y cr v -C�li� �11c�1�1 ,/ <br /> was—c�o�'e�:F_a_ei1►�y has oi,�pr_ox._71_w,cas±e.�u9�d, -tir�es��ox�ed— <br /> nn-s �l^acili r r gQve>r nmeta-�- c_o-ra�c �r <br /> i <br /> _ \ takes—ou+c� "'�'r_a cis�B� 1ee� <br /> Inspection Form Included:Q b—78 <br /> c2o— <br /> Comments Included: — <br /> 3178 <br /> BuditipAl Rep' n m Phone Number In for ignatur Phone Number <br /> INSTRUCTIONS ON BACK71- F <br /> Inco rec EXAM P .L E' 1 2 3 62081 <br /> White Yellow Copy.Operator Pink Copy.LEA <br />