Laserfiche WebLink
Waste Tire Survey & Inspection Report' Inspection Report Number <br /> C81Rec cle State of California — <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 11 1245350 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 'L ?� "?7:' _ Inspection Type(Fill one) <br /> Site Suffix: T J ® Routine Q Re-inspection Q Referral Q Observation <br /> Local _ If Referral,choose referral type(Fill one) <br /> Identifier: 5Q1-(ti,,C aR U CCL' Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address "_4W <br /> Inspection Date / a <br /> fv��f c5� <br /> CA— <br /> Time In Time Out <br /> Business RepQ c Title i : q S ® AM <br /> AM <br /> I Z PM <br /> a,5(, o-L "�-'�5az 7 TNN QPM t� <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (W /PTE) — - (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> El) <br /> ' s D •Active 0 Passenger V Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 41 Indoor <br /> O Q Inactive Q 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 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 /> W�F.Q..Sl1� w.iLt'3 T[✓�. <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Other ✓fraVJt.fAr <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 PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <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 EXTJ N <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 /> W <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <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:§ z <br /> s <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: <br /> Busines Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: IEIXIAIMPLE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />