Laserfiche WebLink
Waste Tire Survey & Inspection Repor, , <br />CalRecycle State of California <br />CalRecycle 181 (Rev. y (cal Survey Form - Page 1 <br />Dept of Resources Recycling and Recovery (CalRecycle) <br />Part A - Survev <br />Inspection Report Number <br />I1 - 1242419 <br />BLUE OR BLACK INK PEN <br />Business Profile <br />Inspection Details <br />TPID - u <br />y <br />Inspection Type (Fill one) <br />Site Suffix: a <br />1 '1 <br />® Routine Q Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />LocalS` G�,,,n, � <br />Identifier: �lv��.� <br />a►� <br />Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br />Business or Facility Name <br />Inspected By Inspector <br />Physical Address <br />39 <br />0 1 f 6rngi..4_4 <br />f <br />Inspection Date -7 / O F / t L� <br />Ji-ac�ti kin CA Q5aDG <br />Time In Time Out <br />Business Rep Title <br />0 AM 0 AM <br />fawn. i 110 �tet+T.<< �c.�e� Kms. <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Tire Count (Whole/PTE)(Fill <br />one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />oZ <br />® Active <br />Q Closed <br />® Passenger <br />Q Altered <br />® Generator <br />Q Hauler <br />• Outdoor <br />Q Indoor <br />GPS Latitude <br />Q Inactive <br />Q Truck <br />0 <br />Longitude - <br />Q Planned <br />Q OTR <br />Q End -Use <br />Q Container <br />Business Type (Fill all that apply) <br />IS New Tire Dealer It 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 Q Other <br />Part <br />B - <br />Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />ENFORCEMENT STATUS <br />V <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />Notice Of Violation Q Extension <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 />Compliance Deadline <br />Q <br />Q <br />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Date p 6 / LN <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 />(Required for NOV or EXT) <br />Q <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q <br />Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q Referred / CalRecycle Enforcement <br />Q <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q In Compliance - No Violations <br />Q <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />Q <br />Q <br />Other: § <br />Comments <br />C � <br />Inspection Form Included: 0111-/ <br />Comments Included: ® <br />4&1 ,to°j-Y,�3' -19 6 7 <br />usi s Rep's Signature Phone Number Ins a tor's gn ure Phone Number <br />INSTRUCTIONS ON B K Correct: is Incorrect: � W 62081 <br />V E X A M 1 2 3 <br />White Copy: CalRecycle Yellow Copy: Operator Pink CopA L <br />q <br />cN <br />N <br />0 <br />f <br />w <br />