Laserfiche WebLink
Waste Tire Sovey & Inspection Re or , Inspection Report Number <br /> State of CaliforniaCalRecycle <br /> — ■ <br /> CalRecycle 181(Rev. (Ca[ Survey Form - Page 1 I1 1.244910 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- /_ - �n Inspection Type(Fill one) <br /> Site Suffix: Vj 3 �/ ® Routine Q Re-inspection Q Referral Q Observation <br /> Local ( 1If Referral,choose referral type(Fill one) <br /> Identifier: ��t�t l�l�l n U n"�1/1 O CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name `l 1� <br /> Inspected By Inspector <br /> q r^ <br /> Physical Ad�res�C7 g <br /> S <br /> 1 Inspection Date 17 <br /> Time In Time Out <br /> Business Rep Title t 0 AM 1 i C C AM <br /> I QPM l t J J QPM <br /> 'Ns Mv C4 0 Gs u;�C1 Se►A, c_ m <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> - <br /> (9 Active • Passenger 0 Generator Q Outdoor <br /> Q Closed O Altered <br /> GPS Latitude _ Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - O Planned Q OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer * 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 B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m M / m <br /> O Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE ti <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> O O Other: <br /> Comments 1f ►l S W 2/ �( <br /> Jl� n fA a(A�- 11 <br /> No 1)1,01( ".& CL)' cyuX5 4onS)cun_ <br /> Inspection Form Included: Q <br /> Comments Included: *Businessp' Sy c 9 � "`— <br /> ignature Phone Number sp or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E X A M R L EL 1112131 <br /> 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop :L LA 0 <br />