Laserfiche WebLink
2 Waste Tire jurvey & Inspection Report Inspection Report Number <br /> CalRecycle State of <br /> CalRecyclel1fornia 181(Rev.10/10) �`'°"10/10) 11 - 1245107 <br /> Dept of Resources Recycling and Recovery(CalRecycle) vS u- -�/ey Form - Page 1 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- i ` Z Inspection Type(Fill one) <br /> Site Suffix: i J "� I 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �U(n 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> �C,t,c.✓V u�-v �rS�r(br-c;�v� .� �7 - l d 1 ��,f��, <br /> Physical Address <br /> Inspection Date <br /> Time In Time Out _ <br /> Business Rep ` Title / / -5-5—O PM � �"") 40 PM_ <br /> �AM <br /> II 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 0 Passenger • Generator 0 Outdoor <br /> D 0 Closed 0 Altered Ai'J,`„ <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive � Truck <br /> Longitude - 0 Planned 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 T� �" n f'- �_ <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder e Other Y PSfr /►J l <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> O 0 0 Notice Of Violation 0 Extension <br /> 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 <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle u) <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <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 /> f <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 In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments <br /> dl k- <br /> fo'kc�- <br /> Inspection FormIncluded: 0 - p. <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspector's.Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: orrect: EXAMPLE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />