|
Y -
<br /> Waste Tire Su ry & Inspection Report •Inspection Report Number
<br /> _ - - - -
<br /> GiYTcH State California N - -
<br /> CIWMB 181(New
<br /> ,.'California Integrated Waste Managenage Survey Form - Page 1 Management Board
<br /> Part(A Survey BLUE OR BLACK INK PEN
<br /> A+..w.c?,' � � 1�N"' r wmh fi��`rrpY ,,'%.. t" .,M A r °.M,a,rr Ur1R✓ 47C+F ,:_'1+t :; V q'F Ay' kMM ✓YvlMl" p^ a,F' Ml Nh r t(i��
<br /> TPID- _ Inspection Type (Fill one)
<br /> Site Suffix: _ -~ J Routine QRe-ins Re-inspection
<br /> Q ReferralQ Observation
<br /> Local ^� If Referral,choosereferral type(Fill one)
<br /> Identifier: Q CHP' Q CIWMB Q Complaint Q Educational Visit Q Other
<br /> Business or Facility Name Inspected B
<br /> p Y Inspector
<br /> Physical\Address "� — � t , �,._ _ ;4;� •� ., ,` � ��`
<br /> Street
<br /> Inspection Date
<br /> City State ZIP Code 1 Time In Time Out 0 AM
<br /> Business Rep Title EE : O0 AM PM EE . O PM
<br /> ;, Operational Status i " Business Role rage T
<br /> Tire Count(Whole/PTE) (Fill one only) III1��t )y" (Fill all that apply) yMrvFILCI xnet
<br /> Ir a �
<br /> s
<br /> Q Active Q< frr Q Generator ( tlaarw
<br /> _� � �✓r�r✓ ar a1 7/"x r�arnlMF!„�'���r�r”
<br /> Q Closed I ? a�Jray Yr'a''Y 'irbN�acf' ar
<br /> GPS Latitude Q a rtMaf, .✓ qtr t : r
<br /> 1 ��lir�,/ w Q Hauler 11 a
<br /> _ Q Inactive Q.T"r`r;( {�, /whyx
<br /> r +rr F✓Fk iA r� ✓ ) :r
<br /> Longitude Q Planned QOTR Q End-Use /
<br /> �, '"„' .,M wr*r �' �r yr✓era-w Y¢.7""�*`5s'an S2r a-,�m .. F :. _.,. ...,..: ...
<br /> Business TypeFtll all�hat�a�liy
<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
<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
<br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires
<br /> ;Q Extension
<br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Complia?�ce 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 a b c
<br /> -Tire Program ID Number from CIWMB
<br /> m
<br /> m
<br /> Q 11 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 In Compliance - No Violations
<br /> Q Q Other: §
<br /> Comments _
<br /> ', ,. c t" ti'" F �;d w fr w`y .W ,,„ ..,�:. (.:.,k ✓ »:i,i 4Y 1 t w
<br /> ..- C 5 f�`„ Y 4a r , w µ s ,a ,w � ,, ✓ r r � mr .,: l~+ r
<br /> ....,.., ".N., d 4 l r'.�Y W M. a .,.. 1 .. d4 ...,..,. � l r, ^ ✓ r✓,1 9 ,.! {
<br /> , x..... a a-,..v Gr s..v., n .. ✓. ,., ,I M ,r�r .. ndr w t ,. ,. a,--.,, wr t sM«{,. .} ^ t
<br /> l s � �'r~ �,,, Y, � t r ,rt"✓ Y �r ✓ ,,. �,,,, a» v r.✓
<br /> a
<br /> r,..,...
<br /> ✓,!,r,� rF,a�, ,tip, a �^ ,.. l � � ,w✓ ark, �r � M.,�rr.r at<�,,,,,r Mrd r:r.� iC �, � ,� � 7 �,;: r �„r., .�, �.,a ,r✓r„ ,M a ,rr w i a a ,,.. � ,
<br /> , _; , ,✓�.,, ,,�� u ,,..Fy ! w;U,wY.,n, ✓[ ,,.. > aw,.... ,�>'� i-4 a.��... .�' aY,'� r. w ,,r, , , ,y,.4:k h �:,Y .,a ���rl' u..... � ai.: ✓ ”,al,,gl„ Y ,y'r � r 7.a, 4 'f '� v �.,-.r,;a.� ��,w; �` aes:,F k> sr ,t cr 8 fiol :,Ar , r t a fry TM,
<br /> @@:,..k � ,. a ,.0 a r.: "� 7.....r ✓ �
<br /> w:,
<br /> .rw«
<br /> ra, �.- 1. .... a.,r , .a , t. ,..�' $,.1. *^,,..,, ,� „ u ✓
<br /> 7'^ lty,<. ✓ "A`✓'mt`a.t l :,,,7.JV' ..FS wa�
<br /> ME.E,..,
<br /> w a ,.Yr v u,. ., r .,r..., ., r s.. Y`,.,�r^�. ,�...� ,, ~t'.� r, :�-: r rY ...,•.a <r a:3 k., r Ff.
<br /> ,;,�rFr.,�.�./'�5a ��,,..w'i', � �.r,✓< �"i',�hr. w '".- a" ✓
<br /> i y ry' ,�,,Y ,Y i+�a✓nw✓„ ,irr`w ,�?"�;y Yz f `r � , w5, �. r rr�"��✓r �, a .�, r",.� $ f^77 .d k rs ,� n Mi F � t d Y' <^f
<br /> � 0�1'�(1'I,G�rftA Mntti:i��l'�i` ,t*•„ r7�9 zrt^`»✓r�^r"}�'fir*�r n � rN w••rr-wr", °+n,w 1�rY:: � cc,� ,�� ..'^--,-''� a p .�,, ,�::<;.,«.v � 1 �,w��F .k ';.,r„ ,� ,,� ri,�a, a,.
<br /> u „ f>rayk" �'� � ,wr.ry rt:;:,( ✓ r�fa, 7a rt i^ .�; ,„. i�rn u[r.�,a. 'ir„� :. r,>� 0. ,.h.# p�` ,H�7'.° ''�4 y, ;4u,4 P`�,r��y, aM�'✓�r:�C�,�,�'`
<br /> �_,-:_ �.�w � i;^.��?tk�r.aaur•�,,g��.,.c���!"18�$,,�r� �5r” CWt�.f�la��tlk .r r"��°�.y"��"1t�.�t;�ltl�n1�7e1"' �1�11 �1 �.,�i'� s`,���tr!� 'r �'��z,rr r�"r��rr r9�11'M�1"t4}1� 1�1�?rrMN
<br /> INSTRUCTIONS ON BACK Correct: Incorrect: s _ 62081
<br /> �..
<br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
<br /> L
<br />
|