Laserfiche WebLink
Waste Tire SL_ rey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1210323 <br /> CalRecycle 181(Rev.y(Cal 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- Inspection' "7o _ � � Inspection Type(Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local � If Referral,choose referral type(Fill one) <br /> Identifier: V\. Jb" N '� Co%N `7 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector @@` <br /> Physical Addrer�C/ ��! 1 - 1 (0 1 1 v <br /> �S�ovl Inspection Date 6 / 2 Q l <br /> Time In Time Out <br /> Business Rep Title U O AM O AM <br /> `` nn----ll I I O A PM O 10 PM <br /> 6-ver, �V0.rO_ t'15�C. 011�k5 <br /> ON Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) ` S (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 4 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> ��S Latitude Q Hauler Q 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 Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body . 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 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 /> Q Q 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) <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 �J_ `` �Y �P `�,rle 1��2Gktnn Aeswe c�i� ^,t-VZ% oa�g_ <br /> cam:- �•� ���;.�,,�5 v�e.�.,` <br /> K) n ceA,S d Concern — <br /> Inspection Form Included: Q q c/ <br /> Comments Included: � tmlf � � <br /> Business ep's Sign ure Phone Number Ins ctor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: V71 EIXIAIMI PI Ll El 111273 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />