|
■
<br /> Waste Tire Su & Inspection Reporteolpection Report Number
<br /> �. State of California
<br /> California
<br /> CIWMB1811(New0,4104) Survey Form - Page 1 1 . 0 1 0 105 8 0
<br /> California Integrated Waste Management Board
<br /> Part A
<br /> S"t, urttih�r ,_tw:;:.,�Sr.vnl'ar�v_'+.s��:�.1.,�rr,�'t��"r.+�...s::;!�.,.. �,}�`��r:lr.rA�t'�vmKr,��'/:,�..�.✓.:ra&�':»y/r/�'t,.,„t✓a..r"�'t :t,:,r.r,ra:ri';,,�r.,Y s uP a�va�k:;a. ., . Br,.�.,,.4:,�Li U/.E1v.u� O.� R B[- L,w/aAC.r YK,I.,aN
<br /> K �P,vr
<br /> k�
<br /> Er'vi
<br /> N
<br /> y;
<br /> fr�' nJv ,i"�-�7r�'� �s'�t,'k �*�.���«;z ^W .�,�1�'�.��arl'��x�«u,a�e:f�..�v���"�:r" ���¢"� 7 �,.,,,,;r -e,.i r" �: "l� i Py ��F a o +,,d k Yyrw^'�✓�r"i.y
<br /> TPID- _ r, _ I Inspection Type (Fill one)
<br /> Site Suffix: (` t.J ® Routine 0 Re-inspection 0 Referral 0 Observation
<br /> Local / i If Referral,choose referral type(Fill one)
<br /> Identifier. G j,l f` .[,{ - ,t i-; 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other
<br /> Business or Facility Name , Inspected By Inspector
<br /> Physical Address !
<br /> / ��
<br /> �t fi/.
<br /> Street --
<br /> .: _ Inspection Date
<br /> I L
<br /> City State ZIP Code Time In Time Out
<br /> Business Rep Title O AM 0 AM
<br /> [QPM � 0PM
<br /> L Operational Status Tf Business Role Storage Type
<br /> (Fill one only) (Fill i s (Fill all that apply) (Fill all that apply)
<br /> TT �7_ (20 Active 0 P "7' aGenerator 0 Outdoor
<br /> CIPS Latitude -.10 0 Closed 0 � " y
<br /> 0 Hauler 0 Indoor
<br /> 0 Inactive (
<br /> Longitude — I-- ! i O 0 Planned 00 0 End-Use 0 Container
<br /> hyB4C�'I"� ,� � ' � f :.ir_ v:.v .st ,_w^<_I/. .. t.�%c,,vk'�.�i,a'.��..v�t�:.a.,:.+'','. .,l .i�., .".�.�,liter:.�rF'rrJ,`�,�.r�.r5�'.r�`'*a.�,""'.,ii��^,s.�o.�c..;�...cuF,r�.r�:k.��,.�.ir3�.16.��" �tw.✓E,r_,r�A��,�.um",ll� gUl1� ;, ^'__"�'a�
<br /> 0 New Tire Dealer 0 Auto Repair 0 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 (2) Other i
<br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS
<br /> U A i HAULING AND MANIFEST REQUIREMENTS
<br /> 0 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 /> 0 0 PRC§42956-Registration/Decal in Vehicle
<br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / M / 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 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 /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations
<br /> 0 0 Other: § —
<br /> Comments {
<br /> II 1
<br /> CIQt/( IJJ l
<br /> t'i - (1 j' (,(q> �' Irjr'
<br /> Inspection Form Included:"
<br /> Comments Included: 0
<br /> Business Rep's Signature Phone Number Inspectors 5(gnature Phone Number
<br /> _ 62081
<br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X �^� n AL i
<br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
<br />
|