Laserfiche WebLink
Waste Tire y & Inspection Repo 'pection Report Number <br /> CalRecycle State of California 1 - 117 5 5 5 0 <br /> A <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- oC/ - a r Inspection Type(Fill one) <br /> Site Suffix: 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. ��yyt � CcAl.t,Oyw Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> e� Inspected By Inspector <br /> Physical Address <br /> 3`f n I G'y-'f Pd r v►�crr� <br /> Inspection Date 0 '2 / c) <br /> S,2o 3 <br /> Time In Time Out <br /> Busi9gss Rep Title / AM O AM <br /> C.A"loHe✓Arflip <br /> / � 4 Q 0 PM f � U 0 ® PM <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 /> 0 ® Active Q Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive ® 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 ® 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 0 Other «e�, rKu <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility LIENFMCEMENT STATUS <br /> Vt A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q 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 / 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 EX ) N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> f <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> Q • 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q Q Other:§ -- --— - <br /> Comments z�'fes r��n�^�•c��� -• i!' D/�I.. � � <br /> Inspection Form Included: Q <br /> Comments Included: ® <br /> - BusinYWsignature Phone mber Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: XE X A P L 1 2 3 <br /> - <br /> ` White Copy:CalRecycle <br /> Yellow Copy:Operator Pink Cop L <br />