Laserfiche WebLink
Waste Tire Survey & Inspection Report inspection Report Number <br /> CalRec cle State of California — <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1242522 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-SurveLf ___ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Q Inspection Type(Fill one) <br /> Site Suffix: 5 3 3 U $ I I* Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: 44 C J Vwp t l^ LC9 t.{�1ttA 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 1 1 Inspected By Inspector <br /> U'n,,ersa� F t�5k Prv�luc 3 q _ (� j (GS(•o�� <br /> Physical Address nn '� <br /> Inspection Date <br /> 1 o cn pn C6 %USto <br /> Time In Time Out <br /> Business Rep Title I 0 AM [ 0 AM <br /> �(\ ` M � � L O � QPM � � 4 -+ QPM <br /> � I1 k ez ��I c.%�� 1`1G,,all�a t \ J <br /> Operational Status Tire Type Business Rote Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> # Active Q Passenger 0 Generator Q Outdoor <br /> D 0 Closed 0 Altered Yv14 <br /> GPS Latitude 0 Hauler 0 Indcof <br /> 0 Q Inactive Q Truck <br /> Longitude - 0 Planned a OTR I ' 0 End-Use 0 Container <br /> Business Type(Fill all that apply) F ll ' W <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 p 1 <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder • Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation Q Extension. <br /> 0 0 <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 m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) n <br /> 0 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 /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities m <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators S In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments �7 7i <br /> ,S. <br /> y ` <br /> X)TA<, AcAe.JI <br /> U cns a f ct. J)C.21'r1_ <br /> Inspection Form Included: 0 7 <br /> Comments a iS7 (Z(A) <br /> B si ss p s Signa Phone Number Insp or's Signat a Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK [Correct: Incorrect: E X A E 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop :L <br />