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08129040730 <br /> 'EI Waste Tire Survey & Inspection Report. Inspection Report Number <br /> a. State Survey Form - Page 1 1 4 - 1 0 7 2 8 0 1 <br /> Ctate ,California1New OC/OG) <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> } TPID- , Inspection Type (Fill one) <br /> Site Suffii. Tl T1 1 O 5 I 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. SQn 760.gt ll f\ CAun�y Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address BE — 5 0 <br /> LKS i sia ce n L_ucc�s_J <br /> I y2o1 G�bral+ec- C..1- i <br /> Street <br /> Inspection Date <br /> I S VQ C' c_N q 5zo_Q Time In Time Out <br /> City State ZIP Code <br /> Business Rep Title m'I—no PM OAM EE O PM <br /> ___-J'_ __ —_ r Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) i �, (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I I. Q Active Q Passenger Q Generator Q Outdoor <br /> O <br /> Latitude I j I Closed Q Altered <br /> GPS �_I-L I �� Q Inactive Q Truck Q Hauler Q Indoor <br /> (� 11/ <br /> Longitude — I I I� �O Q Planned Q OTR WA, <br /> End-Use/ Q Container a <br /> Business Type (Fill all that apply) _ I 111 111 . <br /> Q New Tire Dealer Q Auto Repair Q 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 t'Other LTelecotClnldn�G9�Ip11 CeefJ <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A RULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> O Q <br /> 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!or NOV or EXTJ <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 Referred I 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 j Q 1 Other: § <br /> Comments <br /> t?,ouAn2 t5�ec 't r o-rfned ihts dale 4 t4.o. S�11,�win5 tact +e S. <br /> � ��lc.�_�.�'��_,S_�,ZLon�p:c �r�i.��incs� �• renes 2xi a'� t{vs n_t:�Ce..rs�LgC.� <br /> } talo _Y06An <br /> Inspection Form Included:Q (2oa) <br /> Comments Included:Q _ _ '%&3(78 <br /> Business Rep's Signature Phone Number I ector's Signaiu!e Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E A M L E: 1 2 3 62061 <br /> X P <br /> ■ While Copy CIWMB Yellow Copy Operator Pink Copy LEA ® ■ <br /> it <br />