Laserfiche WebLink
Waste Tire Su. ,iey & Inspection Report orispection Report Number <br /> CalRecycle State cfCelifornR <br /> CalRecycle 181(Rev. (cal Survey Form - Page 1 I1 - 1177762 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 2 � a � 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. S Joaq v;� CoJ n� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name -`1 Inspected By Inspector <br /> Physical Address - <br /> Cis �S2yo Inspection Date S / Q 7 / l <br /> Time In Time Out <br /> Business Rep Title 3 0 AM u 0 AM <br /> p 01�Y1e O 0 PM ` 0 PM <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) t ,Z 0 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' l 0 Active 0 Passenger 0 Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned • OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer 40 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> v <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 EXE N <br /> _ a <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 Z <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 1 Q 1 Other:§ i' ` <br /> Comments 1'J_U Vy`e `V-,9Pt -�fr <br /> Cy 1��� �vci S &A <br /> IW�U� <br /> Inspection Form Included: Q _?G�V2 oz <br /> Comments Included: 0 ��� J � <br /> usiness Reps ignature Phone Number Inspec or's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:0 Incorrect: >� EXAMPLEI 1112L3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © 0 <br />