Laserfiche WebLink
Waste Tire S,, ;ey & Inspection Repor, Inspection Report Number ■ <br />State of California <br />CalRecycle 11 - 1177540 <br />CalRecycle 181(Rev.10/10) <br />(Cal Survey Form - Page 1 <br />Dept. of Resources Recycling and Recovery(CalRecycle) <br />Part A - Giirvav BLUE OR BLACK INK PEN <br />Business Profile <br />V <br />A <br />Inspection Details <br />Q <br />TPID - <br />Site Suffix: 3 1 <br />z 2- <br />o I <br />Inspection Type (Fill one) <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />Rooutti�ine Q Re -inspection <br />® Referral Q Observation <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Local r-- <br />Identifier: Sh J <br />-k-r\ Co <br />If Refer"rai, choose referral type (Fill one) <br />o 0.q' <br />v V <br />Q <br />Q CHP ® CalRecycle Q Complaint <br />Q Educational Visit Q Other <br />Business or Facility Name <br />r <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Inspected By Inspector <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 />010 <br />Physical Address <br />1 Other: § <br />/ 11 <br />Comments ,� CPCLC_"-AtX by (0A V-CcVC) e. S': } C_ <br />Ct G <br />Inspection Date 'Z <br />2 2 1 <br />Time In <br />Time Out <br />Business Rep <br />Title <br />(� C 0 AM <br />-1 <br />0 AM <br />' <br />% 0 PM <br />0 PM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Tire Count (Whole/PTE)�( <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />c�(J <br />Q Active <br />& Closed <br />Q Passenger <br />QAltered� <br />Q Generator <br />PJ1A <br />Q Outdoor <br />AJA <br />O <br />GPS Latitude <br />rJk <br />Q Hauler <br />Q Indoor <br />O <br />Q Inactive <br />Q Truck <br />Longitude - <br />Q Planned <br />Q OTR <br />Q End -Use <br />Q Container <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair <br />Q Trucking Fleet <br />Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br />Q Used Tire Dealer Q Auto Body <br />Q Car Dealer <br />Q Collection Q Crumb Rubber <br />Q Service Station Q Hauler <br />Q Agriculture <br />Q Shredder 6 Other <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 />010 <br />1 Other: § <br />/ 11 <br />Comments ,� CPCLC_"-AtX by (0A V-CcVC) e. S': } C_ <br />—M 16SecyR-& .`Gv\ I� . 12es.Xe.•c�(�c�eS <br />(,V10 wT'.nAc ac�.v��1r�. Close TPsI) - <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Date m / m / m <br />(Required for NOV or EXT) <br />Q Referred / CalRecycle Enforcement <br />® In Compliance - No Violations o <br />���1 Q�� i'Vtn+2(�• <br />Inspection Form Included: Q ZOb — Alk --sZ_{ <br />R <br />Comments Included: Q 1 <br />Business Rep's Signature Phone Number . Ins ector's Signature Phone Number <br />INSTRUCTIONS ON BACK Correct:* Incorrect: E X A M P L E 1112 3 62081 <br />White Copy: CalRecycle Yellow Copy: Operator Pink Copy: LEA <br />