Laserfiche WebLink
Inspection Report Number <br /> Waste Tire 5...vey & Inspection Repor _ � <br /> State of California <br /> CalRecycle I 1 -1176379 <br /> CalRecycle 181(Rev. (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- T� Inspection Type(Fill one) <br /> Site Suffix: ,3 6- ® Routine Q Re-inspection Q Referral Q Observation <br /> Local ` L If Referral,choose referral type(Fill one) <br /> Identifier: �GL1rk ,C(�(( `ilk Ct N-L r (.J Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name lJ <br /> _ Inspected By Inspector <br /> Physical <br /> sical Address <br /> l c ,l'tsc 1 �C-) <br /> CA <br /> Inspection Date <br /> C C.. >>t L�'1 Lh C(53J 0 Time In Time Out <br /> Business Rep Title 0 AM _ Q AM <br /> U 5— 0 P I 3 , ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> / TE) � � r c'1 <br /> ®Active Q Passenger ® Generator ® Outdoor <br /> O Q Closed ® Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> ------ ------------------------- <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 ® 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 / m / m <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <br /> N <br /> 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 /> 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 19 In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> S e&- Com, <br /> Inspection Form Included: ® i" <br /> Comments Included: _G>�t.'-rte- ..Y--- en - <br /> Business Rep's Signature Phone Number ig ture Phone Number <br /> --� 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: v E ) AMP L E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />