|
.Jnspection Report Number
<br /> Waste Tire Surfy & Inspection Report
<br /> St
<br /> tCIWMate of California -.__._..a __... .._. -...._...V. ■
<br /> SurveyForm - Page1 2 . 0 06 6 33
<br /> B 181(New 04/04)
<br /> California Integrated Waste Management Board ._, ......
<br /> Part A- Sur!77
<br /> BLUE OR BLACK INK PEN
<br /> `��
<br /> p4ctf TPID- _ � Inspection Type (Fill one)
<br /> Site Suffix: 1 1
<br /> �r Routine 0 Re-inspection 0 Referral 0 Observation
<br /> Local Y If Referral,choose referral type(Fill one)
<br /> Identifier: ` ✓
<br /> > 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other
<br /> Business or Facility Name
<br /> Inspected B
<br /> Y
<br /> p y Inspector
<br /> T1Physical Address
<br /> Street
<br /> Inspection Date
<br /> City State ZIP Code Time In _ Time Out
<br /> Business Rep Title ® AM u O AM
<br /> _ 7 O PM t G PM
<br /> Operational Status Business Role p
<br /> raf; ✓ C) rr"`" d Vy p,rFra
<br /> (Fill one only) �t (Fill all that apply)
<br /> y 1 . r�i drr4 w
<br /> Active i 0 Generator itl ,
<br /> ��++ Latitude O 0 Closed
<br /> P t7
<br /> i , � �yy. °2t�a' � ^" � '..
<br /> GEEI - I I LLI
<br /> u orf 1 h"iay*�l q✓ a Haller /��a �,��'✓n✓ w r1Ylm
<br /> O CG4, r��°4,r�+w wu✓ ��' t:; w &s'✓1 a n✓a
<br /> Inactive � / �r� ,� ,«✓r �,I+^ i /°
<br /> 0 ✓✓il+�t"✓°✓ �.r�'d"r�'✓t'�' t l�)�r">'�✓ir w �,,Ys{�'��y +
<br /> Longitude — r�w"a�� r End-Use
<br /> i alai ro i
<br /> (�
<br /> 9 � . � � 0 Planned Gr` `�� '^t r �> �
<br /> yr°r� ✓ ,�tk !�k�"'M W+�"h f t
<br /> lS
<br /> SWT r i '.! `y / YJ q Hrv+^h I 9� ( , L/� ✓y�mdM r"l M fyp� ' > / N/M �i%/r 7p7M �t Y/ r9 $ Nr
<br /> �bL.4� �° �.:.v�i .�.f�."�:..�w�._.,..�.��r_........_. ,�� ,.�.±r�lr ...,!,�f✓._ _.,��.�_�r�'w�.✓dt ir',,..:': u.:��.n...��. iJ,c��.�.,�?,��"�1t..��1�`"��:� S;^.d�,..,�!` ^I�y..�:.r.x.. : ,.:�.uld'��.�!.._...6.0 .�✓...,
<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 Q Other ( t
<br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use FacilityENFORCEMENT STATUS ;� '
<br /> V A HAULING AND MANIFEST REQUIREMENTS
<br /> 0 0 PRC§42951 -Waste The 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 M / m / m 0 (2) 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 /> 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 /> .y
<br /> ✓ .: ( r ✓u� ir:/p u✓ ✓ ;"J.,` r .r!1,✓r,✓v.`�:, u',ticn M1^"E Mb;v, 9a✓ rn71P w .! a"//'fib t ✓
<br /> v�� � r� �r,^ +:g.r ✓,,..., ✓4)i �r^'r'd �, �....,.., .... ,.. )d' io.�... l 6 ,' a ,, n,✓ ri«�Cr:,:;:_,�, .:", r y.,,r r ,� *i +�u°6+ wr.,, w S ,v
<br /> '�r`7 „r..:.:,`M' r,?:./,{ r ,/ 4/r✓1,,,3 t � ✓ ,.w7
<br /> /,; ✓ u�'X<., r&rn,ra^;*� 11,1' M^ �',.f. " ”' ", � +�91 /c �h>' `»'„'r'a^ ."”) ^; t, z" ,✓ �s �a ...r
<br /> ✓rl Ypfrg,✓, f✓ K h l:,F✓p. p ' ".,„v° y -6=, F taiti„>� 1 � ✓ a! '��F�' ✓,l, ``✓m N,✓,,.' ,� ✓V ir„ „3./ .✓ e ;✓r.""; .1
<br /> llF,;C"r' 9 .alx /; ✓ 4 'uIY� Std i a'� i" bs rrd u;rrl.,,r I11 ,✓ nl wCGgz "e ✓fit
<br /> 4"°`:^'�, A... vy� t,..,l,n�'+"�,,+ ✓ h v r� � , ,` �' �,.�. „ ' , ., n ly � '�'. �!�" !`tA��
<br /> INSTRUCTIONS ON BACK Correct: Incorrect (�,. .� ,��Mi P LI 62081
<br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■
<br />
|