|
Tire Su
<br /> ay & Inspection Repor spection Report Number ■
<br /> ' XWaste
<br /> State of California
<br /> CIWMB 181 New 04/04) Survey Form - Page 1 1 0. 0 0 r 7
<br /> California Integrated Waste Management Board
<br /> Part A Survey BLUE OR BLACK INK-PEN.,
<br /> ,,.,,"a �l w,.,"^� «�S.q . 'r a.,. aar r r; ry nuw 4� a.a,,.;' rMr'+�, vrw ,n 6a✓�+. r4nro+',a;r, ,r, �w� ;�,t'� a,a ;:r"�X ��yF ,i
<br /> &C' F11�Msar' 15�w1.
<br /> ��,u ra'..^r�rr�,.yt.- r�/�"`�"tis,)u.,'C. ....,��,.v._•.__-_._�- 1
<br /> TPID- Inspection Type (Fill one)
<br /> i (—
<br /> Site Suffix: _f 3
<br /> J L ® Routine Q Re-inspection Q Referral Q Observation
<br /> Local r If Referral,choose referral type(Fill one)
<br /> - i
<br /> Identifier. Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other
<br /> Business or Facility Name T Inspected By Inspector
<br /> Physical Address -- / j I, �E�p� l _ t_ h L4
<br /> Inspection Date
<br /> me In Time Out
<br /> State Z/P Code Time_-_El 5I.-F
<br /> Business Rep Title AM O PM
<br /> i'C U!'-� � , � � l p(�k�� � •.- �, ., )'J)�t l' , ' r I,i d ,a� �P
<br /> Operational Status Business Role {
<br /> (Fill one only) (�tt` (Fill all that apply) 11( i ,�iyr
<br /> Tire fount WholelP•1"E) � !,� � r �d��, r
<br /> Active ( ® Generator tttr, '•�r
<br /> Q Closed QAItC�„„ �a4,rr a1,z /� �ar
<br /> GPS Latitude 04
<br /> Q{� � p 4a yr rt Q Hauler �� e r ;iz”
<br /> W Inactive 0 Truck
<br /> QEnd-Use
<br /> Longitude — i 1 z �W "l,
<br /> Q Planned Q OTR
<br /> I
<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 Q Agriculture Q Shredder Q Other J
<br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS
<br /> VIN--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 Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date M / M / m
<br /> Q Q 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB
<br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT)
<br /> Q Q 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 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 Q In Compliance No Violations
<br /> Q Q Other: § - -
<br /> Comments
<br /> I/ CI
<br /> i J
<br /> G- used, J►y-es C)Yl S)-f r_ i, ;_Sff 3'Cf T-/r10e!f S/�'IC�GL t�F . QsICt L(%.s,
<br /> u I i'P�y�c CJyigc c✓r1 w.-ha.�`�_L Qhl � r _i CQs VrPr�)f It la��y
<br /> Inspection Form Included: Q'
<br /> Comments Included: Q -
<br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number
<br /> _ 62081
<br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X , \/ I:,. r+, ���i �' I. r_
<br /> ■ White Co CIWMB Yellow Copy:Operator __- Pink kCopy:L._- �_ ® ■
<br /> Copy: Copy:LEA
<br />
|