Laserfiche WebLink
Waste Tire Avey & Inspection Repor , Inspection Report Number <br /> CalRecycleState of California11 - 1255823 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <br /> 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- Inspection-3 � � � - O Inspection Type(Fill one) <br /> Site Suffix: l 9 � 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local `n If Referral,choose referral type(Fill one) <br /> Identifier: Jc� �;^ V Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V T"ick Inspected By Inspector <br /> Co`1,-�ocr:0`_ 56.NeS2 <br /> Physical Address J l d <br /> Q 2m S, lac� <br /> Inspection Date 0 I a / I <br /> �ce� 23 1 <br /> Time In Time Out <br /> Business Rep Title1 2 O AM j� O AM <br /> 6 d S OPM Q v * PM <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 /> 0 Active Q Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered /U/td <br /> l <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q 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 Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder O Other I vs_L ! �ca,\e_r 50.v.S <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 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <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 In Compliance-No Violations o <br /> Q Q Other:§ <br /> Commentssi, <br /> �Gqs- V � <br /> Inspection Form Included: Q a 13a� q <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK [Correct: Incorrect: EXAMPLE 1 2 131 <br /> 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:L <br />