Laserfiche WebLink
0 Waste Tire Sui vey & Inspection Report Inspection Report Number <br /> CalRecycle State of California I 1 - 123027-4 <br /> CalRecycle l8t(Rev.y(Ca[ Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE OR BLACK INK PEN <br /> Part A- Survey_ <br /> Business Profite Inspection Details <br /> TPID- Inspection- � � Inspection Type(Fill one) <br /> Site Suffix: � 3 � 5 S 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: SaV,, v;� V'N Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - v1 <br /> Inspected By Inspector <br /> C Ca\ Ct <br /> 1 n 1 1 v <br /> Physical A dress ?j - MJF <br /> ��- <br /> Inspection Date ` / Q <br /> Time In Time Out <br /> Business Rep Title j � � SAM � � :AM <br /> �"C�►�S �` O ��� PM � PM <br /> —� 1n Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) © (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active • Passenger * Generator ' Outdoor ly <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor g <br /> O Q Inactive 0 Truck <br /> Longitude - <br /> 9 Q Planned OTR Q End-Use 0 Container3 <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 0 Other '?to-$k--c M4'vk'j�N3vzc <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 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <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 or EX ) n <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <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 •In Compliance-No Violations o <br /> Q 1 Q LGher.§ <br /> Comments <br /> Al'q <br /> Inspection Form Included: Q194Ae <br /> Comments Included: <br /> mess Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X � I EXAMPLE I 1112H3 <br /> 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © 0 <br />