|
Waste Tire Surly & Inspection Report inspection Report Number-
<br /> - - --- -
<br /> itlZii State of California ¢ -I
<br /> CIWMB 181( e )
<br /> California Integrated WasttManageSurvey Form - Page 1 1 4 - t 0 2 5 6 0 L
<br /> Waste Management Board
<br /> Part --
<br /> A- Survey BLUE OR BLACK INK PEN
<br /> r '
<br /> TPID- _ / Inspection Type (Fill one)
<br /> Site Suffix: L� 1 0 Routine Re-inspection 0 Referral Q Observation
<br /> Local �. If Referral,choose referral type(Fill one)
<br /> Identifier: ` �A _ _^ �i 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other
<br /> Business or Facility Name -
<br /> - Inspected By Inspector
<br /> Physical Address
<br /> Street -
<br /> M^"""f .� Inspection Date / E:)_571 /
<br /> _oii�d
<br /> City State Zlp Code I Time In Time Out
<br /> Business Rep Title 0 AM 0 AM
<br /> 0 PM10 PM
<br /> Operational Status ) r
<br /> �"� Business Role
<br /> Tire C'C1Unt(Whole/PT- (Fill one only) t(! t(tdtt r (Fill all that apply) i>rri �lr" nt
<br /> Q Active Generator
<br /> Latitude 17 -1 O Closed
<br /> GPS 11, Hauler ;B",�trr��,iri° r�r;i�r��r��«����IzMir4�f?tn"�✓,��ri"IJ„'�
<br /> O 0 Inactive
<br /> tL"� r rr �; arr,art I �rrinL a tiny
<br /> Longitude - yin +��ar t F itr nw
<br /> 0 Planned �"i�n ��ti �n� ��t 0 End Use
<br /> _ � r;� t^� 'wF� "r rk'n"s� ✓d'r�s�mr�r,r�Cat�M,,
<br /> r. " � ''v�"�, `�����°-t 2r ���r� �; e d✓ �l�lir id �(�
<br /> r" r,. k✓;rFu "r l+1 rrY ✓ t„ s„r,r rrr ^'r"'",a "�J ,° .,r'::�r�'T rtw �r,* .<,
<br /> �
<br /> Busmesrk�
<br /> ..„e�. � ...:...t ., , r, , ,, ¢ M ..: � r n w f -�,r'rk n,: .„ „ .. r 2b.G';,.,� +” ,�r „n. ,r^✓ 7.'- M $ 4„0 � 4 nqa`d'"�""”" #�
<br /> ..,-
<br /> .,,,.,,.”.-.1� �.f"�rn r,.n,_.,r,.._J...�,,a.i'::u.a�✓,21,.,>. mr���. Y"...�w,W.wn a.,,.wwr".n:~N��� .,��.�a�'�e1 r;7Yr5��,���'� ��!trx� iAC'.r1r. ���Lw-,�..�.� 9%C��"�,P,y.�.�� ar���ti"'� �J�:+u t '�✓, �P`" w '.r
<br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 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 Q Other
<br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS
<br /> - --- ---------.
<br /> V A HAULING AND MANIFEST REQUIREMENTS
<br /> 0 Notice Of Violation 0 Extension
<br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires
<br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline
<br /> 0 0 PRC§42956-Registration/Decal in Vehicle
<br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date
<br /> 0 0 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB
<br /> 14 CCR 18459.2.1 -Submittal of Manifest Forms and Tire Tri Logs within 90 days (Required forNC�Upr9CT)
<br /> 0 0 § p 9 Y
<br /> 0 0 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years
<br /> 0 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 i
<br /> 0 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators
<br /> 0 0 Other: §
<br /> Comments �+� r yJ
<br /> ��S an 1 �'I' - t 4'�. 4: J�:,f—
<br /> I ,a"r v do rii1 rl���r rY, d �^. f �,rr"vii "« ,,err ��yr-r p:u6t �' .�:a�"✓u i",•y �+r.. '✓` mt�;;„r r,. ,,r �"ars r rr^ n
<br /> ytkyrK,r" ,. r �,; w.rr , „. " :x ! !^ti Harr^kGi rrrl ',✓,+a, w...
<br /> ,.,�, �, "trr r d, N a(,:a crr"" t;,
<br /> �,sn r � �r�.+f` r tru'A'
<br /> r
<br /> ,.:�:l a A'd r���3.;:'�§�' u"'"". -,� ,%.,v � tJ ov ,,.,. , Y,r " ;r M.t`n•� ry iy ,tr` _. '..M ,q✓,' tr,fir;r r!"r;,.,.
<br /> �f'��lrr', b s"� �I'•' r r �r" �'� n'n r
<br /> �r r,,:ai>wi ✓da,,.� a `��+,fy",r nh rr s�x//„,nr �,r"` rr'w rp r'. �lr�r� „~�.'"s,'at, I°r t ^'ra��: n�k X��A, w�7 � +'�,..F ,�,-rw�r a af;: '���.
<br /> �.4 w�.� •°/,.. .t...�.. rtL.^ w.r.�.r.�. _ !� ry _ �,.L^ ,�.�N' ;N� !',i:+, a»im^`r' d�i✓ �n..wti a�a.:�r..n. .l- m. -,yi'".-E��':�'>��,�'�2r�u”„�t'�, ,,d ,� � .^_ �62�.'s�r
<br /> INSTRUCTIONS ON BACK Correct:* incorrect: ( �, '"�, V �I� � � W P L� � 1� �� � 62081
<br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■
<br />
|