Laserfiche WebLink
0 Waste TireWey & Inspection Repo" Inspection Report Number <br /> CalRecycle State of Carrfornia p N <br /> CalRecycle 181(Rev.10/10) <br /> y(Ca[ I1 12 2 6 2 3 0 <br /> Dept,of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 <br /> Part A-Surve�_ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � � � Inspection Type(Fill one) <br /> Site Suffix: IIV� y _ 0Routine QRe-inspection QReferral <br /> Q Observation <br /> Local \ / � <br /> � � If Referral,choose referral type(Fill one) <br /> Identifier: �61 �0(1 l/� ` f 1 L Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name n / Inspected By Inspector <br /> Physical Address <br /> �O�\ r� �� � Inspection Date <br /> 1 Time In Time Out <br /> Business Rep Title O AM O AM <br /> l <br /> 0 P I 0 P <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 0 Passenger 0 Generator WOutdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® 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 0 Auto Repair Q 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 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 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 EX7) 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 /> 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 <br /> In Compliance- No Violations o <br /> Q Q Other:§ _ <br /> Comments G 1119' ' ) 0r1 %91— <br /> �l v 1j, 0t 4, i U S),& Of c--f c,tAs l7T ('up Lz f n <br /> Inspection Form Included: Q <br /> Comments Included: ® <br /> B ess Rep's ignature Phone Number Inspe is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: __47 E X A M P 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cy L © ■ <br />