Laserfiche WebLink
Waste Tire Si,-- ✓ey & Inspection Repor Inspection Report Number <br />State of California <br />CalRecycle I 1 -1176664 <br />CalRecycle Recovery <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 - <br />Site Suffix: <br />37 7 L g z - C/ <br />Local, <br />Identifier. >y� <br />Businesses or Facility Name v/ <br />/ �LL/�/ e 541.'/GL,; cva-c ' <br />Physical Address <br />S�-ac-kc I" <br />3usiness Rep <br />Tire Count (Whole/PTE) <br />GPS Latitude <br />Longitude - <br />cp ySzrs <br />Title <br />Inspection Type (Fill one) <br />® Routine Q Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br />Inspected By Inspector <br />a - /o ! <br />Inspection Date a / <br />Time In <br />SOIE 9 -TI E AJ <br />Time Out <br />OAM <br />® PM <br />Business Role Storage Type <br />(Fill all that apply) (Fill all that apply) <br />Q Generator Q Outdoor <br />Q Hauler 10 Indoor <br />Q End -Use 10 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 Q Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />ENFORCEMENT STATUS <br />Q AM <br />®PM <br />A <br />Operational Status <br />Tire Type <br />Q <br />Q <br />(Fill one only) <br />(Fill all that apply) <br />Q <br />Q Active <br />Q Passenger <br />0 <br />® Closed <br />Q Altered <br />O <br />Q Inactive <br />Q Truck <br />Q Planned <br />Q OTR <br />SOIE 9 -TI E AJ <br />Time Out <br />OAM <br />® PM <br />Business Role Storage Type <br />(Fill all that apply) (Fill all that apply) <br />Q Generator Q Outdoor <br />Q Hauler 10 Indoor <br />Q End -Use 10 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 Q Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />ENFORCEMENT STATUS <br />V <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />------ ---- ---- - - - <br />Q Notice Of Violation Q Extension <br />� <br />Q <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Compliance Deadline <br />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Date <br />m <br />/ <br />m <br />/ <br />m <br />Q <br />Q <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />Q <br />O <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />(Required for NOV or EXT) <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q <br />Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q Referred / CalRecycle Enforcement <br />Q <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />(� In Compliance - No Violations <br />Q <br />1 Q <br />1 Other: § <br />Comments <br />l��-�., D �YTdr�+?�> -17a.S�(1�- ri-Lt�l <br />� LGca,✓�., <br />Inspection Form Included: U <br />Comments Included: ®— <br />Business Rep's Signature Phone Number ` Inspector's Signature <br />INSTRUCTIONS ON BACK Correct: Incorrect: E X A M L E 1 2 3 <br />- - X <br />White Copy: CalRecycle Yellow Copy: Operator Pink Co <br />Cz,cei) itb:r-0123 <br />Phone Number <br />62081 <br />