Laserfiche WebLink
0 Waste Tire St.. vey & Inspection ReporOInspection Report Number <br /> Cdeccle State of California — <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1230304 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- _ O 1 Inspection Type(Fill one) <br /> Site Suffix: o� a[1 t ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �n�OV�Ul1 Cuu�}� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> 1- 7 761�U\I- ;n( 1 11 nc'. - 0 EsC,o�n <br /> Physical Address J V <br /> ll3R� tom. l�Uv �°1 <br /> Inspection Date 1 / / 1 S <br /> Time In Time Out <br /> Business Rep r Title I O AM 0 AM <br /> Sia (�G`� ► 'lead (`c1 r' � ® PM 0 PM <br /> -- - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 1 W (Fill one only) (Fill all that apply) (Fill all that apply) (FII all that apply) <br /> ® Active Q Passenger 0 Generator I* Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler � Indoor <br /> O Q Inactive O Truck <br /> Longitude - Q Planned Q OTR Q End-Use 1 Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair • 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 /> 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 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 Exp N <br /> a <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 O Referred/CalRecycle Enforcement <br /> uj <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 /> Comments01w1 OL!r <br /> 1 a, o- (J- rA� +in S 1�� <br /> Ny U10lu� U QI c�f�ctS p�-C UtiLe.�n > <br /> -- a <br /> Inspection Form Included: Q3 <br /> Comments Included: ® �� <br /> Bu ness Rep's Si ture Phone Number Ins tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A M P E 112 31 <br /> 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LE <br />