Laserfiche WebLink
Waste Tire Sup vey & Inspection Report inspection Report Number <br /> CalRec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 11 - 1242237 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � Z � � _ � � Inspection Type(Fill one) <br /> Site Suffix: b ORoutine Re-inspection Referral Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �6c�� Nv,r co�� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Sa . - <br /> Business or Facility Name Inspected By Inspector <br /> MATT ! , <br /> Physical Add ss <br /> V <br /> n Inspection Date Q O / I <br /> S kCvko� C� -ISZaS Time In Time Out <br /> Business Rep Title AMV <br /> I O ' f C) O PM Z 0 APMm <br /> ��� k�l�A 4C ¢y � � ��� 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) Z <br /> Active Q Passenger 0 Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> o Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR 0 End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair I& 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 /> 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 /> — 0 Notice Of Violation 0 Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 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 /> O Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> a <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CalRecycle Enforcement <br /> Ul <br /> W <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance-No Violations o <br /> O O Other:§ _ <br /> Comments <br /> — ���� �j�d\o���c�hS ©C �c�x_S p� l_.O�•�C`n S <br /> Inspection Form Included: Q r <br /> Comments Included: 0 <br /> Business Re nature Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK [Correct:0 Incorrect: M 1 E X A M P L E 1 2 3 62.081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />