Laserfiche WebLink
Waste Tire Su, vey & Inspection Report Inspection Report Number <br /> CalRecycle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 11 - 1177889 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ! a I_ _ /(� Inspection Type(Fill one) <br /> Site Suffix: J lU V 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SCAA \)Cal ^ � � 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> c.14 3 — o <br /> Physical Address <br /> Inspection Date 1 0 / a- <br /> U <br /> Time In Time Out <br /> Business Rep / Title I 1 S S 19 AM Q AM <br /> QPM J � PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ` O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active 0 Passenger 0 Generator ® Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude – 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber // <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ® Other ( f (17u,11e" <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> a <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance-No Violations o <br /> 0 1 0 1 Other:§ <br /> 1_ -__Ll �n <br /> Comments I(7-_ - tC_ ���r7( /L R7� A) l)l� S A d N <br /> k.J�' S <br /> NO 1nk1U5)5 r�f Lk(t-cAs UU+ Coj\Cf-fll- <br /> Inspection Form Included: �0 — fL —– � -1-�jZ <br /> –� (CZvComments Included: � <br /> Rep's Signature Phone Number Inspe,or's Signature Phone Number <br /> �( 62081 <br /> INSTRUCTIONS ON BACK [Correct:* Incorrect: N �J EXAM 1. 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop <br />