Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report Number <br /> cle State of California <br /> CalRecycle CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 - 1177519 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- pn I Inspection Type(Fill one) <br /> Site Suffix: �C 0 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �- If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> -T�5 A 40 3 °� - ( � l <br /> Physical Address F /h\ Inspection Date L4 3 <br /> Time In Time Out <br /> Business Rep Title �1 011 !� O AM <br /> LA)w�- a PM CJ ® 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 /> ' ' ® Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 00 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> ® Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> ® Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> 0 Notice Of Violation 0 Extension <br /> 0 0 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date 0 / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance-No Violations <br /> 1010 1 Other:§ <br /> Comments f 1 1 <br /> Inspection Form Included: 0 <br /> 2oq-127-0600 ©t —3� <br /> Comments Included: 0 <br /> Busin s ep's Signature Phone Number Insp or's Signatur Phone Number <br /> - - - 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: EXAM Ej 111213 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy. <br />