Laserfiche WebLink
Waste Tire vey & Inspection Repoi Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1226317 <br /> CalRecycle 181(Rev. (Ca Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey___ BLUE OR BLACK INK PEN <br /> Business ProfileInspection Details <br /> TPID- Inspection Type(Fill one) <br /> O - - - - <br /> Site Suffix: - �- ` ® Routine Q Re-inspection Q Referral Q Observation <br /> Local " <br /> � i If Referral,choose referral type(Fill one) <br /> Identifier: S J ©UPS ul n C(��{�� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address I 0 1 CS CULJ� U <br /> 1533x, m c. nel Ave <br /> r� Inspection Date 5 0 / <br /> [.�-Nn P CA �53� I � 1 <br /> Time In Time Out <br /> Business Rep Title l Mf, U 0 AM 1 Q AM <br /> U o ® PM O O PM <br /> 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 Q Passenger ® Generator ® Outdoor <br /> GPS Latitude O Q Closed Q Altered Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned ® OTR Q End-Use Q Container <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 /> 1Fu uJx n+l <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other Q"4 1 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility EN ORF CEMENT STATUS <br /> V A !HAULING AND MANIFEST REQUIREMENTS 1 <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 or E)C7) N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <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 - <br /> Q Q Other: <br /> Comments <br /> Inspection Form Included: QA.A AP <br /> Comments Included: ®i <br /> L - ;Business Rep's Signature Phone Number Inspec is Signature P one Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: , E X A M L 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator J Pink Cop :L <br />