Laserfiche WebLink
Waste Tire Survey & Inspection Repor, <br />CalRecycle CalRecyclel1181 (Rev. 10/10) <br />Dept. of Resources Recycling and Recovery (CalRecycle) Survey Form - Page 1 <br />Dart A - ci irvuv <br />Inspection Report Number ■ <br />I1 -1176800 <br />BLUE OR BLACK INK PEN <br />Business Profile <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Inspection Details <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />TPID - <br />Site Suffix: 7 <br />U ( <br />Inspection Type (Fill one) <br />Q <br />O <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q <br />Q <br />® Routine Q Re -inspection Q Referral <br />If Referral, choose referral type (Fill one) <br />Q Observation <br />Local - <br />Identifier: t �G��` <br />�4�,�%�t <br />li <br />Q <br />Q <br />Q CHP Q CalRecycle Q Complaint <br />Q Educational <br />Visit Q Other <br />Business or Facility Name <br />Q <br />Q <br />Inspected By Inspector <br />Q <br />O <br />Physical AddressJ� <br />Q <br />Q <br />Other: § <br />Comments <br />Inspection Date S" <br />C� <br />6 <br />+ <br />1 C <br />Time In <br />Time Out <br />Business Rep <br />TitleII <br />0 AM <br />0 AM <br />.-_ -' 1,, + I <br />I <br />r <br />l Z 16 PM <br />I <br />v i�PM <br />o S J 1 l <br />% YYYI 11�! <br />�% <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Tire Count (Whole/PTE) <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />_.. <br />® Active <br />Q Closed <br />Q Passenger <br />Q Altered <br />4) Generator <br />Q Hauler <br />® Outdoor <br />Q Indoor <br />O <br />GPS Latitude <br />Q Inactive <br />Q Truck <br />Longitude - <br />O <br />Q Planned <br />Q OTR <br />O End -Use <br />Q Container <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair <br />® Trucking Fleet <br />Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br />Q Used Tire Dealer Q Auto Body <br />Q Car Dealer <br />Q Collection Q Crumb Rubber <br />Q Service Station Q Hauler <br />Q Agriculture <br />Q Shredder Q Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V A I HAULING AND MANIFEST REQUIREMENTS <br />Q <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />O <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q <br />Q <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />Q <br />Q <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />Q <br />Q <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q <br />O <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />O <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />Q <br />Q <br />Other: § <br />Comments <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EXn <br />Q Referred / CalRecycle Enforcement <br />(*In Compliance - No Violations <br />Inspection Form Included: / <br />p O <br />Comments Included: ® - - -— <br />Business R9 <br />ep's Signature Phone Number _C 0cl re Phone Number <br />INSTRUCTIONS ON BACK Correct: Incorrect: X , , EXAM 4� L E 1 2 3 62081 <br />■ White Copy: CalRecycle Yellow Copy: Operator Pink Copy: LEA © ■ <br />r' <br />CV <br />a <br />0 <br />Uj <br />w <br />