|
Inspection Waste Tire SL�ey & Inspection Repor� Ins e_ - p .Report Number
<br /> State CIWMB California 1 8 . 1 0 0 6 4 6 5 1 -
<br /> grated Waste
<br /> (New 04/04) Survey Form - Page 1 -,
<br /> California Integrated Waste Management Board J � -
<br /> Part A Survey BLUE OR BLACK INK PEN
<br /> Spectlan Dtai
<br /> r �
<br /> TPID- Inspection Type (Fill one)
<br /> Site Suffix: ^� v _ 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 /> t -
<br /> street - .
<br /> Inspection Date ;
<br /> -
<br /> Time In Time Out
<br /> City y State LIP Gode
<br /> Business Rep Title O AM II( ;II��III O AM
<br /> \\ O PM 9—L«I 0 PM
<br /> } I-A
<br /> r�, s
<br /> Operational Status Business Role
<br /> (Fill one only) tP)d(Ik1at ) x? (Fill all that apply) tdl
<br /> Q Active
<br /> �t tP � Generatortrttf�tsm,l
<br /> r a/a,y >•fd�� w �' wv t -
<br /> (]
<br /> Closed ^y ^d, �4 ,, ,✓" ➢Fra;,nniv¢ r !
<br /> Latitude Q { 01
<br /> n a.
<br /> ,-�:s��(����„�w, ���.1.r,�.?°,�."U�{y«ri�,cei�)-;`4t�-F,�;a+a.�•y„�.ir.,,.-" rt,,.a.+ ,Y¢,a. ry.8. �. ..W! ✓ "^ � ,.�a,F,;.i J� .*"_i-.�""'"4w'T,y§.':drt�"a,.--Nc.'y_�nAuL'���,l�^yf.w�'�,to�ti'���'F�'r��,'^�i%/,r��^''�r.�+h„^;,r°er�"N�w5�.1C�._,-�aMtaL4�p.�e 1dr�ys'�(��1!r7'���a".'�'41 d�>`�a t.„!�'"t��.o,q�"rri��t,��t��rl:"�!l�.a�'t1p�f"�tu+wFqr.)�11"„%0
<br /> Haul
<br /> au�na�r du_,,.le.U�r ,^�
<br /> 0 QInactive
<br /> Longitude Q Planned
<br /> M "
<br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet QGovernment Q Retreader Q Dismantler Q Tire
<br /> tf9r�i`DDerived
<br /> erivedt>„�eriaW�hFuel a�u�L.e
<br /> �.�lGs',thriur
<br /> .�
<br /> I1
<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 /> t
<br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS -
<br /> V I A 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 j
<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 IWMB Enforcement
<br /> O Q
<br /> 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities
<br /> —
<br /> Q Q 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators „No Violations
<br /> Q Q Other: § -------- ---------- -------- — - —_ _. _-.___._ `
<br /> Comments -
<br /> 1 r
<br /> All
<br /> r� ,e
<br /> t u !fix i4 r �ro't i d✓t d 9w .�,, r.¢ �,��,+'"x v�^ :' ,. '"�`»r” -Cdr^'*
<br /> �^i r,�ilir)Irrterats #nIue ,ov
<br /> �f`'"" ,, •�."'.,;+”'^,.77,• r1' w-;„ r , ;;--�-�w- n ,�, " tell ,� ":r '�-"+'r7 ,''�, ,, '" l ,ir
<br /> �, 'Bttne Fte�js 5gne#ure+ , 1�1}a ie Nurrir. "F , y` ! .:Phanmltarhbl
<br /> 62081
<br /> INSTRUCTIONS ON BACK Correct: Incorrect.
<br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
<br />
|