|
ection Report Waste Tire Su � & Inspection Report � p -- p t Number i
<br /> State of California - -
<br /> CIWM6181(New 04/04) Survey Form - Page 1 - 1 D 1 j 2 a
<br /> California Integrated Waste ManagementBoa _
<br /> 9
<br /> Part A- Surve BLUE OR BLACK INK PEN
<br /> TPID- / _ ( Inspection Type (Fill one)
<br /> Site Suffix: 1 J
<br /> L41 110 Routine 0 Re-inspection 0 Referral 0 Observation
<br /> Local *�' If Referral,choose referral type(Fill one)
<br /> Identifier: - _ (�., _ J 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other
<br /> Business or Facility Name v --
<br /> Inspected By Inspector
<br /> Physical Address I � — LILL]
<br /> �.
<br /> -
<br /> Street
<br /> Inspection Datel
<br /> I = . Time In Time Out
<br /> City State ZIP Code _
<br /> Business Rep Title 0 AM 0 AM
<br /> O PM 0 PM
<br /> Operational Status a( r�, `rm a Business Role ."
<br /> (Fill one� only) FIII� (,Ctp (Fill all that
<br /> r �
<br /> Q Actives Fa$r511t / 0 Generator "t t✓ 4
<br /> � 0 Closed
<br /> Latitude �dr ICM t
<br /> GPS � . � 0 Hauler
<br /> Inactive tw >l ✓ � �t� fr
<br /> O 0
<br /> Longitude — 0 0 End-Use r t ,
<br /> Planned „r,ru
<br /> 0 New Tire Dealer 0 Auto Repair ® Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel
<br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber
<br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other
<br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS
<br /> V I A I,
<br /> HAULING AND MANIFEST REQUIREMENTS J'
<br /> 0 i 0 'PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension
<br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline
<br /> I
<br /> 0 0 PRC§42956-Registration/Decal in Vehicle
<br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date :m
<br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB
<br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT)
<br /> 0 1 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years
<br /> 0 1 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement
<br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities
<br /> 0 Q 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ( In Compliance - No Violations
<br /> 0 0 Other: §
<br /> CommentsIT
<br /> t
<br /> n
<br /> r ,. . ,� ::.,: ,,.: a � ,:.,m. ,xd,i a ,. ., v t r "fr !rv.,. r c � ' h,,..✓. ,,.....m. .,.
<br /> (�...:„.,, i~�..� rt _.. ..,.., t nM...,"f wFgh .,r, a � ,. r ,... 1 ,..>� '��.�+,:^, v✓ ..,:, ..,, w �.r,...,... M aM i -✓ ”:-„ ,, ,..,. _,
<br /> mtt .,,,�.. ,,,�,.*r.. „".: !ha c,.,. n u r�Fr r :� �rA.,.t^a f `� ,r- f f a'",�r F. a.,, „�'W ,.dr a ,: ?,: .:� 'i a ....✓a �.-. ,
<br /> r�:, ,.. �•W ,r:e,�^ n �' Y,t ,,,u.. "f� ";r,�.t 1r�',+tu ��,-.�v �4* ,fm. ct ,ver; 5� ,vi I '.�i+w rr,a�' "'
<br /> vrr ��'. ,. ,� a ,:.r� s ,:k"„�f'� s ,+:;: r:.l}}�� �.r +:,.. d .•.,.,.. ..a kr :_, „ 1W�•:r n.f ,:-., ,e e~i' _ ,m ;„;:.:, h � ,a`u,.,. :_�
<br /> �,.k=, `� Y^n,...:•r r r w ,
<br /> s,v:,
<br /> r,. f �..,✓�k'.�f r~ t i,,,:
<br /> ,�.;..Fd�' "�., .,.;Woe,:r m •#',.,: a� tr5a,,.. k.w+ .;... t m-m�P,, :v.,� "� -.; 1,i n,„ f .,.�s„, ,""�. „" , n�°"f✓,�.,,.m,., N �'�.;,;.,*�
<br /> ✓i ri'r Nr,r^ ' T!�4'7rt ��1'Id1�1"� FrA :t�P f�u r ,�'� � 9� fi� _ ;^""' .t G, � ���� �q :r rv"C` �, �"°."y� x�"r�»� _ —
<br /> CAC �r' s �a i Lww9 fc 1+ TMr# S 11#'n�d
<br /> Ii ■ . ._.
<br /> 62os1
<br /> 1 2INSTRUCTIONS ON BACK Correct:* incorrect: A X!A MIP 17
<br /> White Copy: Yellow CoPYO Operator Pink Copy:LEA
<br /> S
<br />
|