Laserfiche WebLink
Waste Tire Arvey & Inspection Repo# Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1244938 <br /> R (CalRecycle) <br /> CalRecycle . (Rev. 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 n S q C a _ I Inspection Type(Fill one) <br /> Site Suffix: J L J ® Routine Q Re-inspection Q Referral Q Observation <br /> Localf If Referral,choose referral type(Fill one) <br /> Identifier: Scv �QtAA udn ()tk Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name l 1 <br /> 1 Inspected By Inspector <br /> V-0mSe � 1,er S ��u (X�► Q <br /> Physical Address 3 J - , , e3 WTTb <br /> Gig <br /> Inspection Date , / l ` / IS <br /> �t,L�o� LA aSw3 <br /> Time In Time Out <br /> Business Rep 1, Title O O AM O AM <br /> PM � U ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> 0 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 10 Active ® Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O 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 �VL l�nvt <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 Q Q Notice Of Violation Q Extension <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 EXE N <br /> r <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 u, <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:§ <br /> Comments w>�s n _\ c{ ok+G z <br /> vJ�n 7 <br /> N� v;��1 ins 6 tis uS dCcz�Cg rn- <br /> 0 <br /> Inspection Form Included: Q <br /> Comments Included: <br /> Business Rep' Signature Phone Number Insp nature or's SigPhone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: � � EXAMPLE 1 273 62081 <br /> White Copy.CalRecycle Yellow Copy:Operator Pink Copy:LFII <br />