Laserfiche WebLink
Oa Waste Tire SL*ey & Inspection Reporanspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1245016 <br /> CalRecycle 181(Rev.y(Ca[ 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- � � � O 1 Inspection Type(Fill one) <br /> �Site Suffix: L 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identifier: 5ck-y\ � V; W�� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Busines[ss or Facility Name v,7 ��`/// Inspected By Inspector <br /> Physical Add sSS <br /> d � 1 V <br /> M� <br /> S ?( Inspection Date O s 1 S / IS <br /> �"" Time In Time Out <br /> Business Rep Title O AM ' I I �+ 4D AM <br /> v PM J Q 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 /> . <br /> . Active i Passenger 9 Generator & Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 10 Truck <br /> Longitude - Q Planned IS OTR Q End-Use Q 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 0 Other �vow ' <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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <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 EXE N <br /> a <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 � t <br /> YAP �hS,cw r &Y\. 0 Y\ awl <br /> t <br /> T1Ap `!w \\J__-— <br /> No \ %Ok UVXIDv`S a (' o�_ Ca r1C"P_c v1 <br /> Inspection Form Included: Q Or-���t � <br /> �- *4�k7 �q�`�6$�32 (�( <br /> Comments Included: I <br /> usiness Rep's Signature Phoner Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: g E X A M P L E 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />