Laserfiche WebLink
Waste Tire Survey & Inspection Repor ., Inspection Report Number <br /> CalRecycle State of California 11 - 1245232 <br /> CalRecycle 181(Rev. (cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � �j � � � © � _ � � 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: ' To L)t �t✓(.vt� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Adaress 1 - 1 (0 / <br /> c � Inspection Date <br /> Time In Time Out <br /> Business Rep TitleO'AM O AM <br /> Z • © ® PM -z— • 5 oPM, <br /> (,' �� ✓yrs <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) / (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ` ® Active ® Passenger ® Generator Q Outdoor <br /> � Q Closed Q Altered <br /> GPS Latitude Q Hauler 111XIncloor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR Q End-Use ® Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® 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 B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I 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 <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 E)C7) 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 <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 Q Other:§ <br /> Comments �, �, _„�1 �� • ( _ a4.-,l <br /> U , <br /> Inspection Form Included: Q /'_X <br /> LI'7 Lf <br /> Comments Included: ® 1 LCIZ <br /> Busi"epg6� fu_re__T_\,_ PhoneNumber nspector's Si Phone Number <br /> �,( <br /> INSTRUCTIONS ON BACK Correct: Incorrect: NJ E X A L 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co LK <br />