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08073140260 <br /> Waste Tire Survey& Inspection Report Inspecti ■ <br /> cra. <br /> on Report umber <br /> Ir CFWMState 1811caillomfa Survey Form Page 1 1 9 1 0 7 .3 4 3 2 <br /> CIWMB 181(New nage) <br /> California Integrated Waste Management Board <br /> 'art A-Survev BLUE OR BLACK INK PEN <br /> Business Profile f Inspection Details <br /> TPID- Q Inspection Type (Fill one) { <br /> Site Suffix: I I ®Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: �.� CoQI ► C� J Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> VI <br /> Business or Facility Name Inspected By Inspector <br /> Physics d ass <br /> �T0 RTD <br /> 1533 Lih�ay - <br /> Street <br /> Inspection Date o g <br /> C,tv J (�T(,,1 J Stale ZIP Code Time In Time Out F] <br /> I O PM <br /> ��SBusiness Rep AM OAM <br /> NiJ_O�JQ PM _F <br /> -- <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r 1 ®Active Q Passenger ®Generator • Q Outdoor <br /> IO Q Closed Q Altered /v <br /> GPS Latitude I I 0 Hauler 0 Indoor <br /> O Inactive ®Truck <br /> Longitude Q End-Use Q Container <br /> O Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer O Auto Repair Q Trucking Fleet (9 Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body Q Car Dealer Q Collection 0 Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ®Other II <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STAT_U_S <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation 0 Extension <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O O 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance'- No Violations <br /> O Q Other: § G <br /> Comments - ��CtY1p/10-�7tZ�nrtl�� ha S -r�y� <br /> 'r^n -c_ <br /> fire po- --b�-�,,,f�Gefr vi,1. /1 Tr ( G ,Fest fnr,MS OrWd. Waifi?t es <br /> ct� o� secP of �m uo N., R16wt Sfi ,TP)z yo33�7, rn4Zn <br /> L_�v1eesfi.fofr►�syr_e�ylllo el o �,tz n67��( <br /> r (1;1 <br /> Inspection Form Included:Q -7 <br /> Comments Included: / 6_70 <br /> Business Rep's Signature Phone <br /> Number( Inspector's Sig ure Phone Number <br /> • KX 8P �J I I� 1 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: I� X a hq P i L �� � 2131 62081 <br /> . White Copy.CIWMB Yellow Copy:Operator Pink Copy;LEA ® . <br />