Laserfiche WebLink
Waste Tire Sup vey & Inspection Report Inspection Report Number <br /> CalRecycle State of California I 1 - 1210554 <br /> CalRecycle 181(Rev.10/10) <br /> (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: I 4) 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 /> f� ` LI�v _ `� 2 r p <br /> Physical Address - 4e�6 LLA <br /> Ltk\`"l corlmc,cx� Arsj� <br /> Inspection Date <br /> Time In Time Out <br /> Ci <br /> Business Rep Title ®AM ®AM <br /> C> Q PM 1 t O (2 O PM <br /> NJ T �J <br /> (1-7, A4,Ci- <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) E7 o (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> !� ® Active ® Passenger ® Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude 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 ® 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 Q Other <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 <br /> 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 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) N <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 /> 2 <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 iloIn Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> <71 <br /> Inspection Form Included: Q _ <br /> Comments Included: a iness R <br /> Buseps Signature Phone Number rl a or's gna re Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: M � � E X A E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink py <br />