|
Inspection Report Number
<br /> Waste Tire -obey & Inspection Rep
<br /> State of California -
<br /> -__
<br /> liWarn � CIWMB 181( e ) 6
<br /> California Integrated WasttManagSurvey Form - Page 1 1
<br /> Waste Management Board - --_. D.. 4 6_.._ __-_-_
<br /> Part A- Survey BLUE OR BLACK INK PEN
<br /> rn5 � � J✓ wa �' rr,�,� 1'$�r�ryr?rr rd,�dagr �rrr i2 �w,��ti'�e�rr w";a2`?""y.r��r,"`�° �'ut��''��� a r7 r�r
<br />} TPID- Inspection Type (Fill one)
<br /> Site Suffix: , 1' �� 7 O (DRoutine 0 Re-inspection 0 Referral 0 Observation
<br /> Local If Referral,choose referral type(Fill one)
<br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other
<br /> Business or Facility Name Inspected By Inspector
<br /> Physical Address – (
<br /> Street
<br /> AInspection Date
<br /> City �— State ZIP Code I' Time In Time Out
<br /> Business Rep Title C) AM / 0 AM
<br /> / / iq�]0 P / r� / ] QPM
<br /> Operational Status ) szw Business Role
<br /> t, (Fill one only) p (Fill all that apply) `
<br /> � A" 1�
<br /> xwvlwisi; r r "k iP
<br /> Active a a �M1� Generator
<br /> � t� ,,r q)P��� hr�lr'�" rip rti•+M1 ��n'" ��x .
<br /> t ra �d a s at fJ a w a�r
<br /> C Q Closed
<br /> Latitude �l0 Hauler
<br /> a41
<br /> _ 0 Inactive
<br /> Longitude – 0 Planned �V f a� 0 End Use ) a� 1aia
<br /> f a $ rt tL�Gaa„
<br /> a:.., ,:, ,.:r _��;:..::...•w.�.,._.:..,..�:, ate.,.,, wNc.Y" ",kLh„„�,'::.r.c:�..�NwN,m�-N-R".N�wm':./J"'aurf�s` :��N ,"r,"tr.`v.,+t"a-P"w'�;yJ,�lxle��aAtJt;�r�'a�''.r N^^�rv•*+w,rk,"i„ �4?'N"I1"�1N'i :N+7w,w�i~kf��N ':.�.�^�.,5�4,'tsi°7.'•�a�k n>. 4ruut��..~'^:�EN?rr u�4r„,a4r'.ti.4r°w'?r`,��F;p9.�,.r!s��r�' aN.�P�%N.�t
<br /> 0 New Tire Dealer 0 Auto Repair Q 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 /> - -— - --------
<br /> V A PRC
<br /> AND MANIFEST IREQUIREMENTS
<br /> dTransport of Tires 0 Notice Of Violation 0 Extension
<br /> 0 O § g p
<br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline
<br /> 0 0
<br /> PRC§42956-Registration/Decal in Vehicle 0 0 14 CCR§18459 -Responsible Entities Complyingwith Manifesting Requirements
<br /> Date
<br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID
<br /> Number from CIWMB j
<br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV'orEXT)
<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
<br /> 'S
<br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators
<br /> 0 0 Other: §
<br /> Comments ,
<br /> a
<br /> r
<br /> No N?^r✓ .r✓ r F wr:, 1 �m ^;r;; r., s r :.: ,x,i, v w :;;.w r„ r,""•, ^" N a 1 „w nr`-?ii r ;:t
<br /> n,.., n ;P ,r... N :w+� ✓ �. ,.,i ., ? p?lbr'::an.,...5, .. .nr .., .:Y...s ,.: ,'. '°�;:%'' § r,;•,.: Y..,u,7 7
<br /> P :..rc wa N w,, c^ ,w�. grrry I f.,�. N n +r. r�r •.0 .. :�w, r i� r,,, ::...^Y rr 7. J.,, w ,.. ,v ai P. rt.
<br /> r to a, .,,. r +.„.. ,r^.a:.,),: r n: M,„-.� . ., '�,:.,r r..�xr✓ q ,i:.. ,q «:.n d i'tr,„r d r.-., ry
<br /> „1✓.;. .( > .^.�... .V,q':4 � ^�,N>q„7 ,. R r w„M.oY,w^P n��,� ar 21 n d�J.i'Gr 4M� >�. M`�: u � ,� "'7” y�:., i„„m , �.::'. ��t' '�. r�wa�,,,;�3�' �` �"�*,"M��.wwa,�✓S'w.� ."`:.»->a�/`r^�.,,'„z#'*� r 6Nwrti;4J T-�1�: ,Vii:,a e a` ;nor,;: � �,�;�::. n /,r w�„r,P.
<br /> a ,
<br /> .., lr r M^ •�',a.;fkl �faa i. ,r:::.,,. ,..'��,„,::,„ , ,< „i. r:.r.. w* � ,. �.w,.. rr n; .nr��nr.._, k�l �'v;: ,.�. .,r,ra''' � .ra,"� "t"r � r'� r,Ar,
<br /> 'rIP; r' � w „„,r rF r ra.: N,r� y nt��-h�-P�r r J. w;^;pf�r,ww,� wPl/w y `r",ry,ci `�, .rrry !✓!h`'k4�'"%. ,r,{�ry�r”°,r r t ��� �,,"f r ,h"��yr ,wM,,. •wn"^�t.... "' %" �"Pa.,.
<br /> INSTRUCTIONS ON BACK 1 Correct:* Incorrect. � Ii*' 1 62081
<br /> - � __ ___
<br /> . White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■
<br />
|