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••L89 <br /> Waste Tire SL*ey & inspection Repori Inspection Report Number <br /> RA= State of California <br /> CIWMB 181 04/04) <br /> I 1 112 7 6 0 0 <br /> California Integrated Was eeManagement Board Survey Form - Page 1 <br /> Bus ess Puof a -- Inspection Details BLUE OR BLACK INK PEN <br /> TPID- � ^; -� -� � , , � _ � � Inspection Type (Fill one) <br /> Site Suffix: �-� 0 Routine ® Re-inspection 0 Referral 0 Observation <br /> Local -l. <br /> `^' �� C If Referral,choose referral type(Fill one) <br /> Identifier: .J � 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> tcPhysics Address <br /> 53A [A. C tine y-C;6 E6 L-Y\ - <br /> Inspection Date 13 / ! 1 C Coq <br /> Time In Time Out <br /> Business Rep Title O AM <br /> (��' F ® PM ® PM <br /> --- --- - - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) / ,r-1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> '^ @ Active 9 Passenger ® Generator ® Outdoor <br /> C 0 Closed 0 Altered <br /> GPS Latitude _ 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler. 0 Tire Derived Fuel <br /> 14 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 114 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 EXT) <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 0 Referred/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 /> CommentsL�mrf - - -- <br /> -A-0 E_ <br /> Inspection Form Included: 01 ' <br /> Comments Included: ® - �igna <br /> �re <br /> J- -c-��p� - - -- 4 - - - - -- - <br /> - _ Business Rep's �PM1oneumber In'{Ye or's'Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect v =X A p 1 2 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator <br /> Pink Copy:LEA <br />