Laserfiche WebLink
Waste Tire Su. ,iey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1210388 <br /> CalRecycle 181(Rev.y(C'al 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- I � 0 � � -7 � _ O � Inspection Type(Fill one) <br /> Site Suffix: 9 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 /> PTiysi A d�ss �e� ��� �s iMQX�`�e _ 1 b l ATT\) <br /> 301 <br /> 1 � �SZob Inspection Date 5 � 2 <br /> 5 koC�c Tov� C <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> ' O PM O ® PM <br /> rye n/la�n 2r <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 /> �l "I 0 Active 0 Passenger 0 Generator 10 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler 40 Indoor <br /> O Q Inactive Q Truck <br /> Longitude _ Q Planned Q 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 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 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 /> PRC§42956-Registration/Decal in Vehicle <br /> QQ 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 N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) 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 1 Q 1 Other:§ A <br /> Comments w�S`� �tZc4e_ )V\$PeC -0e\ l <br /> kk� ll aw,v-_a txtlel-5 ,n dVe�- <br /> 6v`ce r <br /> Inspection Form Included: O — ,- <br /> Comments Included: N� ��v^. � [ <br /> si ss Rep's Sign ture Phone Number lhspec or's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: �XEIXIAIMIPI LJEJ 1112 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />