Laserfiche WebLink
t Inspection Report Number <br /> � � Waste Tire SL. Bey & Inspection Repon � <br /> cdeCcle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 11 - 1210535 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 5; � � - � � Inspection Type(Fill one) <br /> Site Suffix: • Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address -V� <br /> Inspection Date <br /> Time In ((J� Time Out <br /> Business <br /> -Rep p Title A 1 0 : Z <br /> *A1 1 * AM <br /> M•KK. /�� Q.0� s�c� /"lC.`f�Q-- 2� � 0 PM 6� C) � 0 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 /> 0 Active Q Passenger 9 Generator Q Outdoor <br /> o Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned 9 OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) periel* <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 SkA22� �/t �q�j�`tCct,��pV` <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 <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 EXT) 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 Q1 Other:§ <br /> Comments < <br /> 6_� o-� <br /> r <br /> )\C40.5, �Oh.Ce.0 Y\ — <br /> Inspection Form Included: Q , -� /� (y�k00 /*4#-- <br /> Comments Included:® f� O 1 O O <br /> Business Rep's ignature Phone Number Inspe tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: IEIXIAIMIPILIEI 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LFA ® ■ <br />