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Waste Ti°fv Ay & Inspection R..polalnspection Report Number <br /> ■ -111 State of California <br /> CIWMB 181(New04/04) Survey Form - Page 1 I 1 - 1140832 <br /> California Integrated Waste Management Board <br /> Part A- Survey -__ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I l ' ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 1� ` vv�, Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name . Inspected By Inspector <br /> L, 0' <br /> Physics AXddrbAr - in6 <br /> a �_L <br /> 16M' 67CLWyle, <br /> ,A <br /> Inspection Date <br /> C 15 <br /> Time In Time Out <br /> Business Rep Title I O AM O AM <br /> l Z O PM I Z 9 S ®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 /> ®Active Q Passenger 40 Generator jo Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned O OTR <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 Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility FENFORCEMENT STATUS <br /> V A i HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. I Compliance Deadline <br /> 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 ID 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 i 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 ® In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: 4C.p <br /> iness Rep's Signa ure Phone Number ture Phone NumberINSTRUCTIONS O ACK Correct. Incorrect I. 62081 <br /> White Copy:CIWMB Yellow Copy:Operator <br />