Laserfiche WebLink
Waste Tire Su. .vey & Inspection Report -nspection Report Number <br /> cle State of California <br /> CalRecycle CalRecycle 181(Rev.10/10) Survey Form - Page 1 11 1178014 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- S _ O ( Inspection Type(Fill one) <br /> Site Suffix: .S Routine Q Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: S A Y, �QGL1 u 1!1 l l)tL(,fl `� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> l ? Inspected By Inspector <br /> Physical Address 3 I ` ` C—'Sto�]� <br /> Inspection Date <br /> Time In V Time Out <br /> Business Rep Title ® AM ®AM <br /> 0 P V 0 P <br /> k'p AV G�rtr, U-t�rler <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 O Passenger ® Generator Q Outdoor <br /> GPS Latitude Q Closed Q Altered <br /> Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use 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 ® Other Pclsl �Z2, <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date / a <br /> ® 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) <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 <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments 1 f 1 1 I <br /> 0 L <br /> Q , m{Y��11=F1rc\ <br /> Inspection Form Included: Oi <br /> ' G - <br /> Comments Included: — �v�n�* <br /> B siness 's Signature Phone Number Inspe is Signature one Number <br /> INSTRUCTIONS ON BACK Correct:0 incorrect: _ 4 �J E X A P L E 1 2 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink C y' ® ■ <br />