Laserfiche WebLink
Waste Tire SL. fey &Inspection ReporE <br />inspection Deport Number <br />CalRecycle State of California — <br />CalRecycle 181 (Rev. 10/10) Survey Form - Page 1 1 1 1230443 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />Part A - Survey BLUE OR BLACK INK PEN <br />Business Profile I Inspection Details <br />TPID - <br />Site Suffix: <br />Local <br />Identifier: <br />Business or Facility Name <br />� .s , w e- c, �- 6A, <br />Physical Address <br />Business Rep <br />Title <br />Tire Count (Whole/PTE) Z 1 <br />� s <br />O <br />GPS Latitude <br />O <br />Longitude — <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair <br />Q Used Tire Dealer Q Auto Body <br />Q Service Station Q Hauler <br />• Trucking Fleet <br />Q Car Dealer <br />Q Agriculture <br />Inspection Type (Fill one) <br />0 Routine Q Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br />By <br />0 <br />Inspection Date Q / <br />Time In <br />Inspector <br />Y�Xl--7v <br />1 5- / I � <br />Time Out <br />Q AM 7 O AM <br />' ® 0 PM 1 ® PM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />40 Active <br />Q Passenger <br />4D Generator <br />Q Outdoor <br />Q Closed <br />Q Altered <br />Q Hauler <br />0 Indoor <br />Q Inactive <br />0 Truck <br />Q <br />Q <br />Q Planned <br />Q OTR <br />Q End -Use - <br />Q Container <br />U Government <br />Q Collection <br />Q Shredder <br />Q Retreader Q Dismantler Q Tire Derived Fuel <br />Q Crumb Rubber �^ 1 <br />• Other <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />Q <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q <br />Q <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />Q <br />Q <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />Q <br />Q <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q <br />Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />Q <br />Q <br />Other: § <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EXT) <br />Q Referred / CalRecycle Enforcement <br />• In Compliance - No Violations <br />Comments <br />�,, (�'� .��.v,, t��c�s�- rt• C'2 � �SAe c�. e+n .tic» . a <br />W CSS <br />Inspection Form Included: O <br />R ,tS -kk;,m7(4-1 <br />Comments Included:* NLM-0�� <br />Business Rep's Signature Phone Number <br />Phone Number <br />0 <br />6 <br />INSTRUCTIONS ON BACK <br />Correct: 40 <br />Incorrect: <br />IEIXIAIMIPILIEI 1112 13 I <br />62081 <br />0 <br />White Copy: CalRecycle <br />Yellow Copy: Operator <br />Pink Copy: LEA <br />® <br />0 <br />0 <br />6 <br />