Laserfiche WebLink
oe. <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CalRecycle I 1 12 2 6 6 7 0 <br /> CalRecycle 181(Rev.y(Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � - © � Inspection Type(Fill one) <br /> Site Suffix: I ® Routine Q Re-inspection Q Referral Q Observation <br /> Local -U <br /> Identifier: (� 6 G(�I^,)IlD u �j <br /> Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - <br /> L A <br /> Inspected By Inspector <br /> e�"1 S O <br /> Physical Address ES cod <br /> Inspection Date l / r / <br /> Time In Time Out <br /> Business Rep 1' r Title S O AM Q AM <br /> 0 PM 5 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � 5 <br /> Q Active ® Passenger 0 Generator ® Outdoor <br /> o Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> o Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> l New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 1 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 /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS _ <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> - -- - 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 <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV orEXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years U7 <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators = <br /> In Compliance-No Violations o <br /> Q Q Other:§ <br /> CommentskP,, �1�1-�..Vlr�l�z)Q�(��14jr� l� is <br /> RA\ , <br /> 1 <br /> Inspection Form Included: Qcls- (20 I�/I o' L/L v <br /> Comments Included: / 7 11"101)u <br /> Business Rep's Signature Phone Number tnspor's Signature Phone Number <br /> �-�( 62081 <br /> [C:Or:re7ct-INSTRUCTIONS ON BACK Incorrect: � NJ E X A M L 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co L ® ■ <br />