Laserfiche WebLink
03 Waste Tire SRey & Inspection Repor_ Inspection Report Number <br /> Cal Recycle State of California I 1 - 1230108 <br /> CalRecycle181(Rev. (CalRecycle) Survey <br /> 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- a _ © I Inspection Type(Fill one) <br /> Site Suffix: ` ® Routine Q Re-inspection Q Referral Q Observation <br /> Local 1 / If Referral,choose referral type(Fill one) <br /> Identifier: S111n 0(A, �t -� l�{,�� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name lr Inspected By Inspector <br /> 1(a.c� V a <br /> Physical Address 3 "1 - ' V e c( TTo <br /> pT- <br /> Inspection Date <br /> X53NTime In Time Out <br /> Business Rep Title / O AM O AM <br /> �'1 V <br /> &, ) '^ t Y1 CGIISWI V lJ PM 0 PM <br /> I\v�J- �� ],s �k'� S Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 3 0 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> V1 I& Active 0 Passenger 0 Generator 0 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 /> 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 ® 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 <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 /> Q Q 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 EXTJ 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 •In Compliance-No Violations o <br /> Q Q Other:§ y <br /> Comments i1 <br /> �J&A, <br /> jepBusinss <br /> ) JQct 01 <br /> Inspection Form Included: QComments Included: is 's I nature Ph ne Number Insp or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: � E I X JA 1M L 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop L <br />