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d8129840U63 <br /> Waste Tire Survey.& Inspection Report Inspection Report Number ■ <br /> State of Survey Form - Page 1 1 8 - 1 0 7 2 8 0 5�' <br /> CIWMB tet thew nage) <br /> Califomla Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � —f Kil <br /> 0 1Inspection Type (Fill one) <br /> Site Suffix: L4 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: 5cm 3oaquin count-V 0 CHP Q CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> LE�_Gos�co c.,t)_arelnouse I _ <br /> Physical Address 3 1 U1 rt5t Qn L1.4 CetS� <br /> i 2586? 5, Sc1nN1��, G�-. I <br /> Street <br /> Inspection Date <br /> L_� GA 95 <br /> City StaleZ3 7_7e� Time In Time Out <br /> J — IP Geodm <br /> Business Rep Title O0 AM 0 AM <br /> PM m m O PM <br /> OLper�ation�alStatus Tire Type Business Role Storage Type <br /> i (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> 0 Active 0 Passenger *.Generator 0 Outdoor <br /> -- --: I 70 0 Closed 0 Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> i 4--�— I--—I—�J O Q Inactive 0 Truck <br /> � <br /> Longitude _ ( I I Q Planned 0 OTR. . 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair Trucking Fleet Q Government 0 Retreader 0 Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer 0 Auto Body 0 Car Deater Q Collection Q Crumb Rubber <br /> 0 Service Station 0 Hauler Q Agriculture Q Shredder 0 Other Lit b�Ct10f�G.t✓YTer� <br /> I - <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT S A US <br /> am HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 - ransport of Tires Q Notice Of Violation Q Extension <br /> PRC§42951-Waste Tire Hauler Registration and T <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Domptlance Deadline <br /> 0 0 PRC§42956-RegistrationlDecal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred 1 CIWMB Enforcement <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance No Violations <br /> 0 0 Other: § <br /> Comments • A5r6 <br /> �ac�y uses -Tqb��.c-CQy-f_ire._I�-t\�oa�la� T��e.��,�.s�ste���[e Ir_�,►1�. <br /> e_�t�es�►i�e��oth �D4 _CLr,2ain <br /> I (� <br /> cl.1J_"_CL61 Q -ori .Of). kA O �j J 01 CX+i e_,M or QreA>5 con>rer_n—�1 � <br /> Inspection FormIncluded: 0 lifillC <br /> Comments Included:0 -ew '3l7 <br /> Bu es ep's S gnature Phone Number 1406wors Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK KIXIAIMIPILIEI 1-1[2131 <br /> ■ White Copy:CIWMB Yellow Copy Operator Pink Copy.LEA ® ■ <br /> I <br />