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Waste Tire SL► :y & Inspection Report jectionReportNumber <br /> State California Survey Form - Page 1 2 - t '17 CIWMBB 181(New 04/04) <br /> California Integrated Waste Management Board <br /> 20 <br /> 'art A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br />} Site Suffix: I C 7 I l- I - I Q Q Routine Q Re-inspection Q Referral Q Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier: / )()C1QL(,t f t Ot{k" Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> kd <br /> Physio41 Address - �.% ��(1•t l� t, <br /> Ic <br /> Street (, <br /> -)( ( , i ` (-•� r7 ` 2 (_. I Inspection Date <br /> I 1 J l <br /> Citv State ZIP Code Time In Time Out <br /> Business Rep Title 10 AM O AM <br /> 0 PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q <br /> (a Active Q Passenger ® Generator Q Outdoor <br /> Tire Count (Whole/PTE <br /> GPS Latitude U Q Closed Q Altered <br /> Q Hauler Q Indoo � <br /> Q Inactive :,Q Truck - <br /> Longitude - Q Planned Q OTR End-Use Q Container <br /> Business Type <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 (a Hauler Q Agriculture Q Shredder ® Other I{/I(�M 1'. f ( v4 (it r1 �� Y<<(•�( i <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility IENi-URCEMENT STATUS <br /> V ''I A HAULING AND MANIFEST REQUIREMENTS 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 O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O 14 CCR§18459.3-Retention of Manifest Forms and Tire 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 O 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 <br /> Q In Compliance - No Violations <br /> Q Q Other: § J <br /> Comments �Gr� t�•( 1 ri' (` t• C t !?� ( N, ( � - a��uhf r �� 6T u �'�1 Wl,r <br /> ij <br /> J to- i Cols fl►'f �(OK ) Job 1(1- i- (,� Cn it{ l%t �r�(Z i ri r f l L_ or aU6_ - / r <br /> j��t.�t ffluc ) Itj,. C'7L a��� fel< •r��<,f (/l-evj-p � G� '�(s1- 0<,tT( of �%�� n � <br /> t <br /> J(U - (CX"(0yTI_s` r .i'u;;(d _ � VIOillo-if t( yt <br /> fns ec <br /> p tion Form �nc�ude ) <br /> Comments ncuded: - - <br /> i Business Rep's Signature Phone Number Inspector'§§ignatur NPhone Numbe <br /> — --- X I , <br /> - - 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: r �, M P 3 <br /> ` White Copy:CIWM6 Yellow Copy:Operator Pink Copy:LEA <br />