Laserfiche WebLink
Waste Tire Oey & Inspection Repo Inspection Report Number <br /> State of California <br /> CalRecycle 11 -1176695 <br /> CalRecycle 181(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- ,j Inspection Type(Fill one) <br /> Site Suffix: 2- '1 2 d 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: cvtn 7FCtAh k yam, 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 1 I(T' Inspected By Inspector <br /> �t vl mcvyl I I fG �CNVi C.� _ <br /> Physic, 1 Q p� �I£ ii�+, <br /> G S l o <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title (� 0 AM ®AM <br /> O PM 0 Q PM <br /> lr(o mpro p a Y9/f 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 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive 9 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other r <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility ENFORCEMENT STATUS <br /> -- --- --- .......... - ---_ -.__ ----- — - <br /> LV A HAULING AND MANIFEST REQUIREMENTS <br /> — — — -- -- --- 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <br /> r <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ie In Compliance-No Violations o <br /> 0 1 0 1 Other:§ °• <br /> -- - - z <br /> Comments <br /> V%S <br /> ' J� - <br /> t no <br /> Inspection Form Included: 0 <br /> � k <br /> l2 0�) Gff- z� <br /> Comments Included: ® G - ��' <br /> Business Rep's Signature_ Phone Number spector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X 1 E X A M P E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink py L <br />