Laserfiche WebLink
Waste Tire Sul► vey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle <br /> CalRecycle 181(Rev.10/10) 11 Form - Page 1 11 - 1210267 <br /> Recycle) <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: �,j Q2 ( O Routine ® Re-inspection Q Referral Q Observation <br /> Localc v^ If Referral,choose referral type(Fill one) <br /> Identifier. SCAAC—©1l A, O CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V (( Inspected By Inspector <br /> 1"k It �� p, _ <br /> Physical Address 1 l 1 Q l KW16 L)4—)4 <br /> `tai 'S• Gl-►elm �, L-n . <br /> Inspection Date / Q / 1 <br /> 7 6A q!5-ILIO <br /> Time In Time Out <br /> Business Rep Title ®AM Q AM <br /> G ' <br /> `_ C 2 O0 PM � v Ur Z O PM <br /> J k e-,cr` Sv Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/ T ?] 5 <br /> ® Active .® Passenger it Generator At Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned O OTR ® End-Use &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 /> (6 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 I 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 /> O 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m Ffl <br /> m a <br /> Q 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2i <br /> W <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations <br /> O O Other:§ <br /> Comments ` <br /> N <br /> Inspection Form Included: Q <br /> Comments Included: ® <br /> Business ;Signature Phone Number In tor' Si n re Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X lEl X A 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cokf 0 <br />