Laserfiche WebLink
Waste Tire Sui vey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 1196266 <br /> CalRecycle 181(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- inspection O Inspection Type(Fill one) <br /> Site Suffix: Ct �j l 0 Routine Q Re-inspection Q Referral Q Observation <br /> Locall If Referral,choose referral type(Fill one) <br /> ` <br /> Identifier: sctV� SC(;�C:c.�ijV\- Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V Inspected By Inspector <br /> k�icall Address J�cc 1i V,tCkkaVtS6_11bVIL S G '`[ <br /> 16 Lz <br /> sf- <br /> Inspection Date <br /> �fz�c.t4f Cel R��G� <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> ,n Z I 7 0 PM ,S ® PM <br /> !owe. ��:►1�. S_ �_ >^-L•�. <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) _Z y (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> C, ® Active ® Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude ® Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR ® End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet ® 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 ENFORCEMENT STATUS <br /> V 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 / FU / M <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle 0 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXn <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <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 1 Q Other:§ <br /> Comments <br /> Inspection Form Included: Q <br /> D c 9 cS 7 7 '26lc2�_ <br /> Comments Included: 40 <br /> Business s Signature Phone Number l4pqkor' ig6ature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: � ® � EXAM L E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co :L © 0 <br />