Laserfiche WebLink
Waste Tire Survey & Inspection Repor, Inspection Report Number ■ <br /> Cal6ec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 11 - 1226663 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I 3 p Q I Inspection Type(Fill one) <br /> Site Suffix: Routine Q Re-inspection Q Referral Q Observation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identifier: J G J���1 >> n �l>r(1�1� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name I •1 Inspected By Inspector <br /> NO%Ai)�t\''n �/Ci <br /> Physical Address l <br /> �L Inspection Date l 1 / <br /> r"f1UtTleC ri. (A 1 <br /> Time In Time Out <br /> Business Rep Title I O AM O AM <br /> l 3 d ® PM ® PM <br /> - --- --- — Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q End Use ® Container <br /> Q Planned Q OTR <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 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 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date 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 EX7) N <br /> r <br /> v <br /> 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 /> 0 Q Other:§ <br /> Commentsn,- ;C\-C �Ic, ( �� ' J►1SJ 41+C-- I 1 <br /> No VioWianc oc cus.u,� c1�nCern, <br /> Inspection Form Included: 0 - 2°�•���� <br /> Comments Included: ® l 7 <br /> Business p's Signature Phone Number Insp tor's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X ( NJ E X A M E 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop :L ® ■ <br />