Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report Number <br /> cal Recycle State of CaliforniaI 1 - 1242138 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <br /> Survey Fora - 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 Type(Fill one) <br /> Site Suffix: g L 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �� U(V t �� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical ddress \ L - <br /> Inspection Date � / � C) <br /> �l Time In Time Out C <br /> Business Rep Title ® AM ®AM <br /> J f� l lr O PM � � �! � QPM <br /> gelL1s� �ret35 bCAAM ��. <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger * Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> Ca�� Latitude 0 Hauler � Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned O OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <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 <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other vl2_1 V kte�l <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 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 <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 E?C7) N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> Lu <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance No Violations o <br /> 0 1 0 1 Other:§ <br /> Comments ` <br /> LnV <br /> Inspection Form �nc <br /> ncluded: ',1 <br /> Comments luded: ��+ ��� -N�4 3 1Z1725/_:4 -V? <br /> g67 <br /> , ,essRekp'J Signature Phone Number Ins c r' ign ure Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E X A E 1 213 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pin Cpb <br /> ® . <br />