Laserfiche WebLink
Waste Tire Su, aey & Inspection Report •nspection Report Number <br /> Cal Rec cle State of California — <br /> Y CalRecycle 181(Rev.y(Cal Survey Form - Page 1 I1 1230247 <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 1 3 _ ` Inspection Type(Fill one) <br /> Site Suffix: V } 10 Routine Q Re-inspection Q Referral Q Observation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identifier. 50. `k r\ Cc�V Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or�Facility Name p Inspected By Inspector <br /> Physical ess0.� `C1L�2 1 - ' 1 M I V <br /> tl 0 0 W. �0..1��C.� �• - — - <br /> 1 �� Inspection Date <br /> Time In Time Out <br /> Business Rep Title 0 AM 2 O AM <br /> 1 1 O PM J S ®PM <br /> awy\ V&LqN Con c-Y-\ <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 0 0 <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � <br /> Active Q Passenger * Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q 9 <br /> O Q Inactive Q Truck 1 <br /> Longitude - Q Planned 0 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 0 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 ® Other �J�\ v C 1 <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 <br /> 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 m / m / m <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 EXE N <br /> v <br /> 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 /> LU <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 <br /> V <br /> re CA <br /> Inspection Form Included: Q /p/ �/L¢� ?� <br /> Comments Included: oa <br /> Q {L�J <br /> iness i ure Phone Number Inspector Signature Phone Number <br /> 's Sign <br /> INSTRUCTIONS ON BACK Correct: Incorrect: EXAMPLE 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />