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u921704C0U5 <br /> Waste Tire Su 'my & Inspection Repor Inspection Report Number <br /> 'f iIOHZ State of California p, <br /> tit <br /> CIWMB 181(New 04104)- Survey Form - Page 1 �. I 1 1086V487 -, <br /> California Integrated Waste Management Board y r/ <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � � � � t� / I � O I Inspection Type (Fill one) <br /> Site Suffix: 'W^ I ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: L5.0 ,I�t (� Cpu Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> v _ <br /> Business or Facility Name Inspected By Inspector <br /> l Volfoy--Qom hC, i 3 - Iloll] , 6F,5C.40 <br /> Physical Address <br /> \,m_1 N_ b_� <br /> StreeF ( Inspection Date V IIIA (`��J IIII CI�_JI <br /> City o ode Time In Time Out <br /> City State Gt, Code <br /> Business Rep Title O AM Q AM <br /> PM I I 5 i i� PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> a;a <br /> Active ® Passenger Generator Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> .'O Q Inactive Q Truck <br /> Longitude – i i, i Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet p Government Q Retreader Q Dismantler Q.Tire Derived Fuel <br /> Q Used Tire Dealer IS Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other I I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> WJMIHAULING 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 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIW MB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EJCT) <br /> Q Q 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/ --IWMB 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 C-ompliance - No Violations <br /> Q Q 1 Other: § <br /> CommentsN <br /> ID - ' <br /> `o�— - u —U-tl 1 S- - -t,— =-1�cc�— <br /> X10 �D ClIMcaj_�S_OUZD.CR,t r1 - <br /> QS�1C 1 �=1e INN 11 12f <br /> Inspection Form Included: Q 2 <br /> Comments Included. Q — <br /> Business Rep's Si ature Phone Number Insp tot's Signature Phone Number <br /> INSTRUCTIONS ON BACK EE IXIAIMIPILIE[ 1 2 3 62081 <br /> White Co :CIW Yellow Copy:Operator Pink Copy:LEA <br />