Laserfiche WebLink
Waste Tire Sl?vey & Inspection Repor. Inspection Report Number <br /> CalRec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form ® Pale 1 1 1255915 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey BLUE OR BLACK_INKPEN <br /> Business Profile Inspection Deta]s <br /> TPID- q 2 /_ ` - u Inspection Type(Fill one) <br /> Site Suffix: `J t(J J <br /> ® Routine Q Re-inspection Q Referral Q Observation <br /> Local1 If Referral,choose referral type(Fill one) <br /> Identifier: w V l h wu c�.i Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Inspection Date <br /> LCL+ �;,, coq-- 9S__3 3(:) <br /> Time In Time Out <br /> Business Rep Title O AM 7— /) O AM <br /> _ ✓ &PM "� ' v 6 PM <br /> perational 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 /> 0GlActive • Passenger 46 Generator QOutdoor <br /> GPS Latitude O Q Closed Q Altered Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned 0 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 /> Q Service Station Q Hauler Q Agriculture Q Shredder • Other � ry <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 Q Q Notice Of Violation Q Extension <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 <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 EXE 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 /> W <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance-No Violations o <br /> Q Q Other:§ 1 1 z <br /> Comments _ <br /> �'Gu Gwi J'lv�c <br /> o r <br /> Inspection Form Included: Q0-000V /�ja� (/2FU <br /> 11 <br /> Comments Included: Q. LL d 1 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: RR:q IEIXIAIMIPILIEI 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />