Laserfiche WebLink
Waste Tire Sus vey & Inspection ReporJOlnspection Report Number �. <br /> CalRecycle State of California I 1 - 1245049 <br /> CalRecycle 181(Rev. (C,, 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- � � � ry � Inspection Type(Fill one) <br /> Site Suffix: "� 4D Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: V i� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Vo\lQtAan o� <br /> Physical Address <br /> 2 1 AvvkoC� <br /> Inspection Date O / 0 -3 d S <br /> v) <br /> Time In Time Out <br /> Business Rep Title 0 AM � n s � � O AM <br /> O PM •L & ISM <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 • Passenger Generator 40 Outdoors <br /> GPS Latitude 0O Closed Q Altered <br /> Q Hauler 0 Indoor Z <br /> o Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <br /> 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 it Car Dealer 0 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 <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 O 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 EXE n <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q O 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 /> Comments <br /> OL N <br /> nv-- � <br /> VC I ,,,sG.S hp <br /> As <br /> r r� <br /> Inspection Form Included: Q <br /> Comments Included: <br /> Business R 's Signature Phone Number Inspe is Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect: X4V]jEjXjAjMjPjLjEj 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />