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Waste Tire Su �y & Inspection Repor Inspection Report.Number <br />State of California <br />CIWMB181 (New04/04) Survey Form -'Page 1 I 1 1088432 _ <br />California Integrated Waste Management Board Y �7 <br />Part A - Survpv BLUE OR BLACK INK PEN <br />Business Profile <br />Inspection Details <br />A <br />TPID - <br />Site Suffix: <br />1 <br />D <br />�3�J <br />Inspection Type (Fill one) <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />® Routine Q Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />Local <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q <br />Identifier: <br />14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />Q <br />Q CHP Q CIWMB Q Complaint <br />Q Educational Visit Q Other <br />Business or Facility Name l`��� <br />L—� � o l 1 r E-, <br />Physics AtlGress <br />Inspected By Inspector <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q <br />O <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q <br />O <br />Inspection Date <br />Time In <br />Time Out <br />Street <br />d,i (�4 <br />City % State ZIP Code <br />Business Rep TitleO <br />AM <br />O® <br />_ <br />O AM <br />i O <br />Other: § - - -- -- - <br />PM <br />I V ®PM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />) <br />Tire Count (Whole/PTE) / <br />f <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />® Active <br />Q Closed <br />® Passenger <br />Q Altered <br />® Generator <br />Q Hauler <br />® Outdoor <br />Q Indoor <br />-- — - O <br />GPS latitude <br />- - — <br />Q Inactive <br />Q Truck <br />Longitude— <br />Q Planned <br />Q OTR <br />Q End -Use <br />Q Container <br />Business Type (Fill all that apply) <br />® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br />® 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 I <br />I <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />Q <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q <br />O <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 />Q <br />O <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q <br />O <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q <br />O <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 />O <br />O <br />Other: § - - -- -- - <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Datem / m / m <br />(Required for NOV or EXT) <br />Q Referred / CIWMB . Enforcement <br />® In Compliance - No Violations <br />ction Form Included: O <br />Comments Included: Q <br />INSTRUCTIONS ON BACK <br />White <br />Signature Phone Number <br />rre In orrect:VX qj <br />e CI Yellow Copy: Operator <br />Pink Copy: LEA <br />Phone Number <br />62081 <br />