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Inspection Report Number <br /> ■ Waste Tire S ey & Inspection Repor� - p p <br /> State of California i g <br /> -.; CIWMB 181(New 04/04) Survey Form - Page 1 3 I, 0 J <br /> California Integrated Waste Management Board _ <br /> Part A- Survey _ BLUE OR BLACK INK PEN <br /> Business Profile "` Inspection Details <br /> TPID- I r� Inspection Type (Fill one) <br /> r <br /> Site Suffix �j �j F � Q Routine Q Re-inspection Q Referral Q Observation <br /> Local - - If Referral,choose referral type(Fill one) <br /> Identifier: �' \•1 0 tz0 9 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> PhysallIiH <br /> icA• ddress — I ` 1Q� <br /> ttt---��� <br /> Street <br /> Inspection Date j=Os <br /> /Sta<e !P odTime In Timee Out <br /> e ; ...._ LT] <br /> Business Rep Title AM O AM <br /> 0 PM 0 PM <br /> L n , � <br /> " e <br /> rNwOperratiional Status ire Type <br /> Business <br /> eole Storage <br /> Ta( only) (Fill apply) ( ll that apply) :: (Fill <br /> allPePI <br /> Y)Tire Count (Whole/PTE) Q Active Q Passenger Q Generator QOutdoor ' <br /> O Q Closed Q Altered <br /> GPS Latitude y Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <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 Q Other t,t� c'_A�t„� s 1 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS-S <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q 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 Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> Q Q 14 CCR§18459.1 -Tire Program 1D Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <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 Q Referred/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 Q In Compliance - No Violations <br /> 0 Q Other: § <br /> Comments / <br /> U) y C)\LarM gt P.n_<?.t—n�A E,T r-- <br /> � _ A <br /> J <br /> •A- ,, .! : f—•, / r)nP, 1w'�_,='��,�r•� - t�..J1 ,_,"t L;- �- ��l� �— 't -,,( �' ri t1 � <br /> Inspection Form Included: Q, <br /> Comments Included: Q - - - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> ® ` , � 3 � r -.�__. 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: n A p' L �. <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />