Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California 1 J - 1255855 <br /> CalRecycle 181(Rev.y(CalRecycle) Survey <br /> S rvey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) dei! Y 6r Form�N <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile I inspection Details <br /> TPID- 1 8 o Inspection Type(Fill one) <br /> Site Suffix: 5 g 1 1 Q Routine Q Re-inspection ® Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SO—r �dQq vih rte,���� Q CHP Q CalRecycle® Complaint Q Educational Visit Q Other <br /> Business or Facility Name b 1•� Inspected By Inspector <br /> Physical Address l b 1 /1�AT <br /> � Inspection Date Q LA� / 1 <br /> 5�� / p g <br /> Time In Time Out <br /> Business Rep Title 0 AMO AM <br /> I . .2_ g i PM �— 0 PM <br /> a.r\ <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 /> 0 Active * Passenger •Generator ! Outdoor <br /> Q Closed Q 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 /> 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 /> 0 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date 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 EXT) <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 u, <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 /> CommentsSecs CDV1n <br /> DA- A�n:S Cl -1Q <br /> Inspection Form Included: Q <br /> Comments Included: <br /> Business Rep's Signature Phone Number Ins ctor's Signature Phona Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: EXAMPLE 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />