Laserfiche WebLink
f- <br /> Waste Tire Su. Bey & Inspection Report Inspection Report Number <br /> CalRecycle State of California o ■ <br /> 1 CalRecycle 181(Rev. (Cal Survey Form - Page 1 I1 1177521 <br /> 1 Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> - <br /> Site Suffix: '�` Q Routine Q Re-inspection Referral Q Observation <br /> Local < If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP a CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name � � Inspected By Inspector <br /> RZ 6 � <br /> PhysicQ &dress - 0 �, 1 <br /> (Ai <br /> / J ( Inspection Date tom( / `� / <br /> U('�l✓��n ` � � Time In 1 Time Out 1 <br /> Business Rep y Title ( 0 AM r 0 AM <br /> MAS- I ' � /1(/ 0 PM j, - q ( ® 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 /> IS Active Q Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered 01A <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned ® OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) vbft <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 ® Other 6,,L <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 / 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 EX7) PL <br /> N <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 /> 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 /> Comments <br /> D _ v3 <br /> Inspection Form Included: O ^^ �I <br /> Comments Included: ® {` ` [Jl 1 <br /> Business Rep's Signature Phone Number Insp or's Signature hone Number <br /> INSTRUCTIONS ON BACK FCorrect-0 Incorrect: EXAM L E1 1213162081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy. ® ■ <br />