Laserfiche WebLink
Waste Tire Su%e & Inspection Report Inspection Report Number <br /> CalRecycle y p p _ <br /> State of California 1 1 1177884 <br /> CalRecycle 181(Rev.y(Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Inspection Type(Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �" t If Referral,choose referral type(Fill one) <br /> Identifier: SACS J a�,tr�ln r� COi,t,n�' 1 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> LCs 3 - <br /> Physical Address I CS COh <br /> 3:�A' p W . � S�n\ 1� L► nR� a r <br /> I'CCkl✓ Ch �� Inspection Date ' 0 <br /> Time In Time Out <br /> Business Rep Title 1 0 AM AM <br /> �,A V � PM � � � ® PM <br /> `TCI,SOn�f &Sk1"f4"4_ I"`�Y1G� <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 15 I, (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> J "I 0 Active ® Passenger ® Generator 0 Outdoor <br /> O 0 Closed (♦ Altered <br /> GPS Latitude 0 Hauler Indoor <br /> O 0 Inactive ® Truck <br /> Longitude — 0 Planned ® OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 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 <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> 0 Notice Of Violation 0 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 <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> a <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 /> uj <br /> w <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments <br /> Inspection Form Included: 0 <br /> Comments Included: (46 <br /> B Hesss Signature Phone Number Insp c or's Signature Phone Number <br /> INSTRUCTIONS O ACK Correct: Incorrect: EXAM 112 3 62os1 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:, E <br />