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' 1 F <br /> Waste Tire Survey& Inspection Report InspectiVIRIpO ARAll d <br /> State ClWMt181 California Survey Form Page 1 1 6 1 Q 7 9 4 7 6 <br /> GWMB 181(New..g <br /> California Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 3 4 9 �Kij:�d O ®Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: �r,r.,,/✓l !" - G 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name U' Inspected By Inspector <br /> lPhysics Ad_N-t13 q _ 1 dress MC) l <br /> L-- <br /> Street <br /> Inspection Date <br /> Circ State IC—od­e­j Time In Time Out <br /> mBusiness Rep Title 0 AM 0 AM l 0PM 0PM <br /> -- - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r ' 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> i0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 Inactive 0 Truck <br /> Longitude - I I I0 0 End-Use 0 Container <br /> 9 I j I 0 Planned 0 OTR <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 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 I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A 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 /> PRC§42956-RegistrationlDecal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <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 EX7) <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 I 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 0 In Compliance - No Violations <br /> 0 ' 0 Other: § <br /> Comments / C..�� //��/�C11i_L�Hl�C Len/_. C'S' /_�LlC44.11c/ ;nar�yuc.le_ <br /> { <br /> Inspection Form Included- 0 <br /> yb-F—abzj <br /> Comments Included:0 <br /> Business Rep's Signature Phone Number Inspector s Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:0 Incorrect:7V'K?1(1� q I EJJXJ A N` E l P iL 2 3 62081 <br /> ■ White Copy.CIWMB Yellow Copy.Operator Pink Copy.LEA ® . <br />