Laserfiche WebLink
r <br /> Waste Tire .5u, .ey & Inspection Repon nspection Report Number <br /> CalRecycle State of California I 1 - 1210495 <br /> CalRecycle and <br /> R(Rev.y(cal 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- I C _ O Inspection Type(Fill one) <br /> Site Suffix: J 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local1 If Referral,choose referral type(Fill one) <br /> Identifier: un ��a��1 1�n 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Lo(�; A��� rpn 5 - 1 l G U <br /> Physical Address 11 Ave- <br /> r 5 <br /> Q_,A A (o Q ck , <br /> j�^ l J � Inspection Date / l / 3 <br /> ` 1 J Time In Time Out <br /> Business Rep Title *AM * AM <br /> l b 51 5 <br /> 1 QPM QPM <br /> sivnG6T 0-vi - <br /> Operational Status *Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) C 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> J 0 Active (ID Passenger ® Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> O 0 Inactive 0 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 ® 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 <br /> Part B - Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of Violation Extension <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 <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 EXT) N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 2 <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 ®In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments n I_' J L� I I fe_ l ! A�Fc_ <br /> N <br /> oy 1'014�iv_►s b j cA,-t'" (r�C On Cef n, <br /> Inspection Form Included: 0 n 3) <br /> Comments Included: 0 4z/ :13 <br /> sine s Rep Signature Phone Number Ins tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: � � � E X A L tE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink C py' ® ■ <br />