Laserfiche WebLink
02 Waste Tire Survey & Inspection Repon i..,pection Report Number ■ <br /> CalRecycle State of California 1 1 - 1226379 <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: b 7 ( Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local \ If Referral,choose referral type(Fill one) <br /> Identifier: � y)�� � /� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name V Inspected By Inspector <br /> A-1.+- <br /> Physical Address �,ylti <br /> Inspection Date / 1 '-7 / I <br /> L�)cJ I �� � Time In Time Out <br /> O AM O AM <br /> Title <br /> Business Rep <br /> Z ' 0 Z ® PM G 7 ®PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> 0 Active 0 Passenger Q Generator 0 Outdoor <br /> o <br /> Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) -- <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ® Other T4,-zAe_A �,s,/uzq <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m N <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 — (Required for NOV or EXT) - <br /> 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days a <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> Lu <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities — — <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance-No Violations o <br /> 0 0 Other:§ -- ~ <br /> Commentsim <br /> c�hrlsL � z Glp �bCc, I�—mac <br /> 1L' <br /> Inspection Form Included- <br /> Comments Included: 0 <br /> Bu ness Rep's Signature Phone Number p ctoP- I ture Phone Number <br /> ,-,( 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X � NJ EXAMPLE 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />