Laserfiche WebLink
Waste Tire Su ey p p. v & Inspection Re oftInspection Report Number <br /> cle State of California <br /> Cal Rec — <br /> Y CalRecycle 181(Rev. (Cal Survey Form - Page 1 I1 12 4 2 5 4 6 <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 �y Q O Cf © Inspection Type(Fill one) <br /> Site Suffix: ll d Q I ®Routine Q Re-inspection Q Referral Q Observation <br /> Local1 If Referral,choose referral type(Fill one) <br /> Identifier: Se40 �C9u�L4. C�ttinQ CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> (��n Inspection Date / O r7 <br /> Time In Time Out <br /> Business Rep���✓� 1�IN �In �) Title F,�_ 61FII_ �_"C � N •AM 5 ®AM <br /> 1� L V J V Q PM O PM <br /> S� V►D IPS ` fIV4 P'r <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 /> ' ' u ® Active ® Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude 0 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 S 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 <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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date 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 EXT) N <br /> a <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 /> 2 <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators I&In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments diYA CTU �/ <br /> ND \) ivjA'b--)S or afcus - �unCl2r�1 <br /> Inspection FormIncluded: Q <br /> Comments Included: I A CI���? ` Z 6_6 <br /> Business Rep's Signature Phone Number Insp or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: EXAM E _�112131 <br /> 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop :LE <br />