Laserfiche WebLink
2 Waste Tire <br /> Ske & Inspection Re <br /> or, , Inspection Report Number <br /> CalRecycle State of California <br /> CalRecycle 181(Rev.10/10) <br /> Survey Form , Page 1 1 - 1230109 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- q Inspection Type(Fill one) <br /> Site Suffix: '1 `7l �l $ l 0 ® Routine Q Re-inspection Q Referral Q Observation <br /> Localc If Referral,choose referral type(Fill one) <br /> Identifier: SO/lcl JOUILA'1 1 CO Lklr�k� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Such— t _ <br /> Physical Addressl U� l Q CS(o-rTo <br /> �1v15 1 W� M o r <br /> C Inspection Date <br /> "Tf L� GA J�� Time In I Time Out <br /> Business Rep Title e AM 1 O APM <br /> 0 � S p PM <br /> `Jn Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> 5 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> jo Active Q Passenger • Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive 41 Truck <br /> Longitude - Q Planned Q OTR Q End-Use S Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ®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 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 <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 /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years In <br /> 0 <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 /> Comments1 I 1 <br /> n'Iy 1►at LVL,6�e� L 1 r 1 fl �U ¢I l� �O <br /> fV o V 10LaAy--n of WcA':� 6+ cof1C&zrn- <br /> Inspection Form Included: Q -16`l <br /> 49Comments Included: <br /> Business Rep's Signature Phone Number Insp or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: ?,$< 7;*�w E I X I A I M P L E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink C.&,-- <br /> o y:LE © 0 <br />