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Waste Tire S.-- Bey & Inspection Repo. ,. Inspection Report Number ■ <br /> State of California <br /> CIWMB 181 04/04) <br /> I 1 - 114 0 7 2 5 <br /> California Integrated WaseeManagementBoard Survey Form - Page 1 <br /> Part A-Survey BLUE OR BLACK INK PEN_ <br /> Business Profile Inspection Details <br /> TPID- � Inspection Type (Fill one) <br /> V <br /> Site Suffix: 3 • Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local - If Referral,choose referral type(Fill one) <br /> Identifier: ���� , ���� C;IJVt 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> in <br /> Busess or Facility Name Inspected By Inspector <br /> ra c L i 5-hZ S _ <br /> Physics AddresQ 3 G 1 A`6yov <br /> Inspection Date <br /> CA RSaoC <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> ,f O PM Q PM <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 /> // <br /> 0 Active 0 Passenger a Generator 0 Outdoor <br /> O ® Closed 0 Altered <br /> GPS Latitude 0 Hauler IS 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 /> 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 Other 10,3-t-f� <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V j 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 /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements DateM / 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 /> 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 /> Comments <br /> See Larme-ak <br /> i <br /> Inspection Form Included: 0 J A �'' <br /> Comments Included: • ` +I�S1� -- - Q t"�6� L�-7 <br /> Business Rep's Signatu Phone Number ctor'A NPAure Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect. �'; 62081 <br /> — _ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Cop :L A <br />