Laserfiche WebLink
Waste Tire Sup Bey & Inspection Report inspection Report dumber ■ <br /> CalRecycle State of California 11 - 1177686 <br /> CalRecycle 181(Rev. Survey Form - Page 1 <br /> Dept of Resources Recycling and Recovery(Cal(Ca[Recycle) <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: 6 CZ 3 L1 —1 l ® Routine Q Re-inspection Q Referral Q Observation <br /> Localr^ If Referral,choose referral type(Fill one) <br /> Identifier: SCLA �(�Gb�� �(3(�Y�, Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> f�c-A V\_A -�) <br /> Physical Address (� �( — <br /> l b 9- t E , A /Vve,- <br /> Inspection Date <br /> �4n__�+OYN 64 g5OLO - Time In Time Out <br /> Business Rep Title fin AM _ Q AM <br /> 0 PM ' 0 PM <br /> ��,���� Lc..�I•hb`r Dune✓ <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 /> ® Active Q Passenger ® Generator Q <br /> Outdoor r <br /> PSLatitude O Q Closed Q Altered .� //4 <br /> G0Q Inactive ® TruckQHauler Q Indoor <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 40 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 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 Q - -- Q Notice Of Violation Q Extension <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 O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / 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 Q1 Other:§ <br /> Comments <br /> Inspection Form Included: O �el,7 I 7 <br /> Comments Included: Q '7 <br /> - -- -- — - <br /> Busin 's Signature Phone Number I ect 's ignature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A M E1,41213 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co y:L ® ■ <br />