Laserfiche WebLink
® Waste fire Self vey & Inspection Report <br /> Inspection Report Number <br /> calRec c9e State of California 1 <br /> J CalRecycle 1$1(Rev.10110) S1 14�!®� ®r� a Page 1 1. - 1177633 <br /> Dept of Resources Recycling and Recovery(CalRecycle) 0..f A tl e <br /> -Part-A-- Survey---- ---- ---- - - — -- ---- --- — ,---_---.--_BLUE-OR BLACK-INK-PEN- <br /> Business <br /> LACK-INKPEN-Business Profile Inspection Details <br /> TPID- Inspection <br /> Inspection Type(Fill one) <br /> Site Suffix: L 9 -7 g 1 Q Routine 10 Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Ad ress !"1 A 7-VQ <br /> Inspection Date C) ,_j / q 3 <br /> A4cA,,-_C ct.— Time In Time Out <br /> Business Rep TitleU AM 0 AM Z <br /> I 4 0 0 PM 1 V *PM <br /> VG.4u a - ©�V, e tr <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole ET , <br /> S Q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active 0 Passenger 40 Generator 40 Outdoor <br /> O 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 /> • New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 411 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 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 I m a <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 o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <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:§ `, , w \ <br /> Comments r�Oyve OY\ NVI� A`C`= Q-v\k <br /> a S VN CA? <br /> Inspection Form Included: e — ZC`—g19-32 9� <br /> Comments Included- — <br /> Bu ' Rep's Sig u Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Corr t: Incorrect: E X A M P L E 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />