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® =„ Waste Tire <br />State of California <br />CIWMB 181 (New 04/04) <br />California Integrated Waste Management Board <br />Part A - -Survey <br />Business Profile <br />Site - <br />Site Suffix: <br />Local �� <br />Identifier: <br />Business or Facility Name <br />Physics ddre3s C)+— <br />a 3,y & Inspection Rep t <br />Survey Form - Page 1 <br />16 1Z_ zEas¢ 41ihe flue <br />Nr.vl-�� <br />Business Rep y <br />Tire Count (Whole/PTE) <br />GPS Latitude <br />Title <br />Inspection Report Number <br />I1 - 1141322 <br />BLUE OR BLACK INK PEN <br />Inspection Details <br />Inspection Type (Fill one) <br />® Routine Q Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br />Inspected By Inspector <br />�q - l 0 4l.�a AambA <br />Inspection Date 9 / (�z l / 0 <br />Longitude0 Planned 0 OTR Q End -Use I Q Container <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair aTrucking 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 <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility ENFORCEMENT STATUS <br />- — - -_ Notice <br />- - <br />V ' A � HAULING AND MANIFEST REQUIREMENTS � <br />�Q � <br />--- —-- -- - - --------- e Of Violation 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 <br />Q <br />Time In <br />PRC § 42956 - Registration/Decal in Vehicle <br />14 CCR § 18459 -Responsible Entities Complying with Manifesting Requirements <br />Time Out <br />Q <br />Q <br />' <br />I2PM <br />Q <br />OAM <br />O PM <br />— - <br />Operational Status i Tire Type <br />Business Role <br />Storage Type <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />Q Referred /CIWMB Enforcement <br />0 Active <br />Q Closed <br />Q Inactive <br />Q Passenger <br />Q Altered <br />®Truck <br />9 Generator <br />Q Hauler <br />® Outdoor <br />0 Indoor <br />I <br />0 <br />O <br />Longitude0 Planned 0 OTR Q End -Use I Q Container <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair aTrucking 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 <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility ENFORCEMENT STATUS <br />- — - -_ Notice <br />- - <br />V ' A � HAULING AND MANIFEST REQUIREMENTS � <br />�Q � <br />--- —-- -- - - --------- e Of Violation 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 <br />Q <br />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />14 CCR § 18459 -Responsible Entities Complying with Manifesting Requirements <br />Date m / m / m <br />Q <br />Q <br />14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />Q <br />Q <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />(Required for NOV or EXT) <br />Q <br />Q <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q <br />Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q Referred /CIWMB Enforcement <br />Q <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />® In Compliance - No Violations <br />Q <br />Q <br />Other: § <br />Comments LJim"apecbw '0 <br />o ro zyy� - orc c)�_�cn�� <br />ction Form Included: <br />Comments Included: Q — <br />s <br />B ep' <br />INSTRUCTIONS ON BACK f <br />White Copy. <br />Phone Number Insp to nature Phone Number <br />ncorrect: % (E XI A ,M P E � 62081 <br />© ■ <br />Yellow Copy: Operator Pink Copy: LEA <br />