Laserfiche WebLink
Waste Tire SLPey & Mspeetion Report inspection Report Number <br /> CalRecycle State of California I 1 - 124- 5076 <br /> CalRecycle l8f(Rev.y(Cal Survey Form _ page I <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � ('— � fA („ � _ j Inspection Type(Fill one) <br /> Site Suffix: l J 1 lJr ( 0 �Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: � �1(,�� V Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 6 <br /> •�� Inspected By Inspector <br /> i <br /> Physical Address - / UJ)�)'V&' <br /> L eek C>Is- i) Inspection Date 7-- <br /> !�t l./ <br /> ��d� Time In Time Out <br /> Busiine�,ss�t�Rep �j-��C�L�Gu �rC9D Title j!, O AM 0 AM <br /> ��, <br /> J V OIPM Z_. & ®PM <br /> Operational Status Tin: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 /> Active Q Passenger to Generator Q Outdoor <br /> o Q Closed Q Altered <br /> ��� Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> -ongitUde - Q Planned 16 OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q 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 PI Maki <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 /> Q Q PRG§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements DateM / 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 EXE 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 /> 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 ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments ICA a�r"y' <br /> 0 i aU'L_� ter Gf_"Z�L' r L' <br /> Inspection Form Included: Q <br /> Comments Included: <br /> Ziiusi;esep's Signature Phone Numbernspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: EXAM L 0.1 1112131 <br /> 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pin Copy: ® 0 <br />