|
Waste Tire Su & Inspection Report spection Report Number
<br /> State of California {�
<br /> CIWMB 181(New 04/04) Survey Form - Paige 1 10 1 4 D 1 6
<br /> California Integrated Waste Management Board J J - ----- -------
<br /> Part A- Survey BLUE OR BLACK INK PEN
<br /> Business Profile Inspection Details
<br />} TPID- Inspection Type (Fill one)
<br /> Site Suffix: -> t 'Q Routine Q Re-inspection Q Referral Q Observation
<br /> Local If Referral,choose referral type(Fill one)
<br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other
<br /> Business or Facility Name Inspected By Inspector
<br /> Physical Address
<br /> I Street ` `
<br /> Inspection DateLLJ
<br /> City v , - JL V State ZIP Code Time In Time Out
<br /> Business Rep Title : LFQ AM _ F70 AM
<br /> 1 O PM O PM
<br /> Operational Status� b�r+,. , Business Role'
<br /> (Fill one only) 1111)rrt �r� (Fill all that apply) t
<br /> Q Active r�la �� bV Q Generator
<br /> O Q Closed
<br /> GPS Latitude m • frl d Q
<br /> ,w+w p r wur rA �r Hauler
<br /> -- Q Inactive
<br /> O '
<br /> End-Use
<br /> Q Planned rant ytt
<br /> Longitude C '
<br /> r+„err 'f rr„�.,d�b g, mr �: �"r'r^ u,:^ n w�� :.r +u r.>*• ,� Y1:,' �, �..r.a� w& �..;3'�,^�uu^u�"n''�� .n �.•r.: ».:
<br /> :,.;;: r ,;„ S , ,4r:,..0 i° t '4 M..h.. y Yr„ ,;r uta �C:.:raa �t.::... 0 ✓'w'r:r-::6 u,!v r n,,;rr ✓ry ���✓ire . v „ ,f..rr. + r +� r
<br /> „�y ” ., r ~a �.r,,�-. wb t s a a w a,.�'” «.. 'T`t �+r IX �±r"r,� ���/atd`,I.NmtY�.F.�r4�'?.�7t�Cl� ,��',4C.:,v"a?F.E,?.r� " r."�W'^�Nux.+t!7nN�.�r.���nn�wlr._��ast'•.r�14�n�,3�„�W.�"�M.WL'_;r:�L,.�';�.r�d,�W2�a:.r!Mi,Mw ?rM.w,..•r/r tF�,',";�uti�!�:M;r.a F.n<"�..1rtA4 d1�°.F a�u��FY...�.�__,.:r a ,
<br /> c.-...,.....�._..
<br /> Q New Tire Dealer 0 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
<br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS
<br /> V A HAULING AND MANIFEST REQUIREMENTS
<br /> 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 /> 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB m m m
<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 1 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement
<br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities
<br /> i
<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 kl
<br /> 1 -- --
<br /> '
<br /> 't
<br /> �' >
<br /> k s,;� n ;. .+<"', ":.. 'r"kr"M•an ti; i+, "waa f ea.*rayrrF'".^r pr:aw^,'z ! w'S+m/ '
<br /> r N M r"i ;:.M ,�N ('�' "�,as a 't✓r"! ,fir+ ir.r,.�� '�",7.':'t '�
<br /> J�;t
<br /> �,.1„
<br /> � ,•••;, �w ..:r � w� rr�+~r::. :rwy :� ,:� A ,�� r,.+^%Mr� rety� r^ ,^'�,
<br /> a ,ir�r" +rre�vy"'u;l� .�' '" ,�an, d.:.. rn a,,4 - - -a�`�'�•un.';, r aw � Y ,y.�O'�i,w�*' rw u?re�r j;o r�c"r :I�" /i � �'n� ��,,t>nt ;t � '�"_ : .
<br /> L'Onfrtd;e reaaa �� rl, Ure w fa,n e r " rr itt one;Number
<br /> f
<br /> tI .rs., tr<at
<br /> 620
<br /> - ®_ -- -
<br /> - - 81
<br /> INSTRUCTIONS ON BACK ' Correct: Incorrect: X tI I f
<br /> ■ White Copy CIWMB Yellow Copy:Operator Pink Copy:
<br /> LEA
<br />
|