Laserfiche WebLink
0 Waste Tire Su,vey & Inspection Report Inspection Report Number <br /> CalRecycle. State of California I 1 - 1230150 <br /> CalRecyc1e181(Rev.10/10) 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- e Ipection Type(Fill one) <br /> Site Suffix: ® I �Routine QRe-inspection Q Referral <br /> Observation <br /> Local ` 1 r If Referral,choose referral type(Fill one) <br /> Identifier: S a�V�Gv'�In,n `0-a Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> It — <br /> Business or Facility Name Inspected By Inspector <br /> �'(_o Fns � Wa,l 31 <br /> - ES c) <br /> Physical Address t <br /> 0 Niq t4i on S�' <br /> /, Inspection Date 7 / O / S <br /> 5��3 Time In Time Out <br /> Business Rep c�t Title 0 AM [,{ 0 AM <br /> C\,�G�i� `�C.�o`j �CQ. 1`. -�5►�l{ 2 VZ Q ® F M � � J S ® P M <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 /> ®Active Q Pasenger Q Generator Q 0 <br /> L,It��r <br /> O Closed Q After <br /> GPS Latitude Q H le <br /> O Q Inactive Q Truck Q Indoor <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 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 /> Q Q 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 N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXn <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 /> 2 <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:§ ff _ l <br /> Comments W u-SL �j f p " i(�Z �3 1L 1 d �J� <br /> (�y.,J U S r1 AQ N�;;0 � c�l f acts �2j-c cin Ct n_ - l- <br /> \y4U(�j' 'mss rn ►'S � G �►'1'S <br /> Inspection Form Included: Q <br /> Comments Included: 09 (off 31 <br /> Bu6rhess Rep's Signature Phone Number Inspe is Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:4D Incorrect: � � E X A M 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:L ® ■ <br />