Laserfiche WebLink
Waste Tire Su. Bey & Inspection Reporp Inspection Report Number <br /> CalRecycle State of California — <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1230073 <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 Type(Fill one) <br /> Site Suffix: -2 D g 0 I 4D Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ��� ��Q��j�� CC5 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name / Inspected By Inspector <br /> Physical Address <br /> VX <br /> �� Inspection Date � � / -2, 2 � 1 5 <br /> Time In Time Out <br /> Business Rep Title 10 AM 0 AM <br /> C) 0 <br /> ' t PM S 46 PM <br /> 5GSe__ OC�o� eYvtiCe -eClr�. <br /> - -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 2 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' • Active 40 Passenger 0 Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler Indoor <br /> 0 0 Inactive 0 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 <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 40 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 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 /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date}') <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle I� I <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> 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 /> 2 <br /> W <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 0 In Compliance-No Violations <br /> 0 0 Other:§ <br /> Comment �S c � <br /> a.�CC�u �•nP `h�2 C � �Y�P dh <br /> s : Ct <br /> e <br /> Inspection Form Included: 0 <br /> Comments Included: <br /> B s' s 's Signa ure Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS O ACK �orrect:eX NJ Incorrect: EXAMPLE 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />