Laserfiche WebLink
Waste Tire O"u, vey & Inspection Repuet Inspection Report Number <br /> CalRec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1245392 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- /� ) �/ v /� i Inspection Type(Fill one) <br /> Site Suffix: "l ( 9 0 (� 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Cq v7 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 'i5U r t Tri,;,Wr- 5AWI <br /> Physical Address <br /> S _ <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Titlet AM AM <br /> I <br /> 1 a I : + 3 OPM � � � QPM <br /> l,Lsf� h 3�✓ns ykc�,,: <br /> -- perational 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 /> i Active Q Passenger i Generator Q jOutdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> o Q Inactive goTruck <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 Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> JL �V�V�Q Service Station Q Hauler Q Agriculture Q Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A I 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 <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 EXT) N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Uj <br /> W <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <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 Pr�tw_'KA I-Xe op a � GYt_ <br /> " <br /> � G�'it��ra lJ lo1c.tr2y <br /> Inspection Form�nc�uded: Q <br /> Comments ncuded: Q B Zoe 40-14 <br /> _ i ess Rep's Si re Phone Number nspector's Signatuff Phone Number <br /> �-�( <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X 4 NJ EXAMPLE 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © 0 <br />