Laserfiche WebLink
2 Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State California I1 - 1176834 <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> ,. —,iness Profile Inspection Details <br /> D_ Inspection Type(Fill one) <br /> Ite Sffix:u /�� <br /> i -- d ® Routine Q Re-inspection Q Referral Q Observation <br /> Local ` �-, If Referral,choose referral type(Fill one) <br /> Identifier: �t� JQ���� �C!C/1� +`-'1 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> cctk%s � kc�r -t - l D , <br /> Physical Address I <br /> I Inspection Date <br /> CA �5a1q 3 <br /> Time In Time Out <br /> Business Rep Title O AM J O AM <br /> y I ®PM i' ® PM <br /> tJC.,_t� rV�L (,�f1�rr,t 41';M 1aVX -- - -- _. <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 /> Q Active ® Passenger 4 Generator Q Outdoor <br /> 0 4F Closed Q Altered '",l ' ` <br /> I GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> I <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> �6usiness Type(Fill all that apply) <br /> C) New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Jsed Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber - ' <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Oft Other � J4-71 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V j A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q iQ PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q j PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956- Registration/Decal in Vehicle i <br /> Q Q 114 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O0 114 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) i <br /> Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q )14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q 1 Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities —_ <br /> `Q 1 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations I <br /> IL Q Other:§ <br /> Comments - - - - — <br /> ection Form Included: Q _ <br /> M "� <br /> Comments Included: ® ` -� - �� <br /> Business Rep's SiggoM Phone Number sec r' Ig re Phone Number <br /> _ -_ <br /> 11 <br /> INSTRUCTIONS ON BACK Corr ct: I orrect: q E A E 1 2 3 62081 <br /> White Copy: aIR Yellow Copy:Operator Pink Copy'LEA <br />