Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report Number . <br /> CalRecycle State of California 11 - 1226271 <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE OR B LACK INK P E N <br /> Part A-Surve _ BLACKINK <br /> Business Profile Inspection Details <br /> TPID- / ) Inspection Type(Fill one) <br /> Site Suffix: 1 33 -7 3 41 l &Routine Q Re-inspection Q Referral Q Observation <br /> Local �+ If Referral,choose referral type(Fill one) <br /> Identifier: l✓� ��-ctv\� �11 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Call <br /> C\��� ) II__ <br /> Physical Address� Cl Ml� <br /> Inspection Date { l l <br /> j� 1 <br /> `�' Time In Time Out <br /> Title O AM PM AM <br /> Business Rep I& J ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) , ® ® Active ® Passenger ® Generator ® Outdoor <br /> PS Latitude Q Closed Q Altered Q Hauler Q Indoor <br /> G <br /> � Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) — <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 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 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 Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle (Required for NOV or Exr) <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred CalRecycle Enforcement 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 /> Q Q Other:§ <br /> Comments <br /> Inspection Form Included: Q ��-- <br /> Comments Included: Business Rep's Signature 9 P one Number p t s S' n re - Phone Number <br /> W V 62081 <br /> • <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A M P E 1 2 3 ® ■ <br /> ■ <br /> Pink Copy:LEA <br /> White Copy:CalRecycle Yellow Copy:Operator <br />