Laserfiche WebLink
M Waste Tire Survey & Inspection Report <br /> Inspection Report Number <br /> Cal Rec cle State of California — <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1210432 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 3 Inspection Type(Fill one) <br /> Site Suffix: & Routine Q Re-inspection Q Referral Q Observation <br /> Local ' <br /> If Referral,choose referral type(Fill one) <br /> Identifier: San y0�,t,U ui n W Ll� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name l 11 11 Inspected By Inspector <br /> �DIcS�C So(�UU <br /> (A n l'\J Qj9a l <br /> Physical Address �0-TT 0 <br /> - <br /> ���� Inspection Date `7 / Q <br /> Time In Time Out <br /> Business Rep Title O AM //�� O AM <br /> D ® P(vl 3 • V v ® PM <br /> --- -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) /X (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 9 Active Q Passenger ® Generator Q Outdoo <br /> fr <br /> O Q Closed Q Altered IV/A <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive A Truck <br /> Longitude — Q Planned 49 OTR, Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q 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 0 Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other Ljmbv„ �16AU_ pl <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 Q - Q Notice Of Violation Q Extension <br /> 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 N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <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 Q Referred/CalRecycle Enforcement <br /> 2 <br /> U, <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire},Generators <br /> in Compliance-No Violations o <br /> Q Q Other:§ z <br /> Comments `, nt- U0a_A�� 1 f I W\�q e N <br /> 1 V r <br /> ow1 <br /> Insp ection Form Included: t,4 <br /> Comments Included: ® <br /> W-01)7f� �37sr0 <br /> s ess ep's Sig tuYe Phone Number Insp is Signature Phone Number <br /> INSTRUCTIONS ON ACK Correct: Incorrect: EJXJ I L LK 1 2L3] 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink py ® ■ <br />