Laserfiche WebLink
r <br /> Waste Tire Akey & Inspection RepUrt Inspection Report Number <br /> State of <br /> CalRecycle CalRecycle11f81(Rev.10/10) 11 1242446 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection^ � O � Inspection Type(Fill one) <br /> Site Suffix: � 7 O ", 7 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local /^� ` If Referral,choose referral type(Fill one) <br /> Identifier: '� 5c�cy`�� W k3 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> '10Business or Facility Name I Inspected By Inspector <br /> ?'OF_'4F_'4csJnS <br /> A 39 <br /> Physical Address <br /> Inspection Date 07 l 7 ` L <br /> Time In Time Out <br /> Business Rep Title �^7 0 AM �^\\ 0 AM <br /> G- 2 O • PM 2- V 40 PM <br /> ��j 'F_`X3,Y\-S <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 0 Passenger O Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler & Indoor <br /> 0 Q Inactive Truck <br /> Longitude — Q Planned OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 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 /> 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 /> Q Q 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 EXn 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 /> w <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <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 /> CommentsCM <br /> �o V:A GN:ohS cw 'k-c c)CS cis Cec e) <br /> Inspection Form Included: Q r 4 <br /> Comments Included: • Q �� Ze� {6g—.mow 1 <br /> Business Rep's Signature Phone Number Insp tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E�X�A�MJPJLJEJ 112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />