Laserfiche WebLink
Waste Tire SL. Bey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1177829 <br /> CalRecycle 181(Rev. (cal 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- Inspection Type(Fill one) <br /> Site Suffix: g © , ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ��n ��^ ��{�� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> N C W u ► _ b CCS\).ef- <br /> Physical Address 3 9 [ d C <br /> So e !CAO Si- J 111 <br /> r q �� Inspection Date 3 0 '-7 , 3 <br /> v'v� ^ `` Time In Time Out <br /> Business Rep Title O AM O AM <br /> e— 0 PM ® PM <br /> 3 o_s us r n erre 1 Pl"4 M8 c_ <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 Passenger 40 Generator Q Outdoor <br /> O Q Closed Q Altered NIA <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned • OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) uJ 1 <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 Papel- <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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 N <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 EX) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 /> No vl ukw'i v ns or w rAs o+ c/t,nce.rn- <br /> Inspection Form Included: Q ` <br /> Comments Included: '—"" Fs� - —��1 -P6ne <br /> _ sines 4, .gnat4e Phone Number Ins tor's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK [Correct: Incorrect: ve NJ EjXjA�MjPjLjEj 11 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />