Laserfiche WebLink
Waste Tire Survey & Inspection Reporn Inspection Report Number ■ <br /> CalRecycle State of California181( I 1 - 1242319 <br /> CalRecycle 181(Rev.y(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- N7 � Inspection Type(Fill one) <br /> Site Suffix: Is Routine Q Re-inspection Q Referral Q Observation <br /> Local �' If Referral,choose referral type(Fill one) <br /> Identifier: S A(1 J 0a I Li r ��*��� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> S CV) � s� C�i�v���e,}� 3 `� - � n 1 Cs ATO <br /> Physical Addr ss <br /> 1 .10 S_ C�h�-�o12��. l,n_ <br /> � <br /> CA �ISZi-f0 <br /> Inspection Date r7 <br /> / 1 / ► -1 o�liI <br /> Time In Time Out <br /> Business Rep TitleiL O AM O AM <br /> /- QiUJ" U 3 , 0 PM I 11 PM <br /> �Svn \&' ?&j 4S. J- jrvV C12- <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) r I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill ail that apply) <br /> ® Active 46 Passenger ® Generator • Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O 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 /> Q Used Tire Dealer Q Auto Body S 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 /> Q Q <br /> 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 / m / 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 EXT) A <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 <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 0 In Compliance-No Violations o <br /> 1010 Other:§ <br /> Comments Q-J)_„�„t S 1 1 r U <br /> � X11 <br /> 1t, vin ' 115 or c.-0QAS 1(11�sl. <br /> Inspection Form Included: Q 1 (\, <br /> Comments Included: ® `� to <br /> Bus ess e ' nature Phone Number Ins ctor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E X A 1112131 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:L ® 0 <br />