Laserfiche WebLink
Waste Tire 0 jey & Inspection Repoi inspection Report Number <br /> Cal Recycle State of California <br /> CalRecycle 181(Rev.y(Cal Survey Form - Page 1 I 1 -1176679 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey _ _ _ BLUE OR BLACK IN_K PEN <br /> Business Profile Inspection Details <br /> TPID- , Inspection Type(Fill one) <br /> Site Suffix: i y 7 _ ® Routine QRe-ins Re-inspection <br /> Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: � 1 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> `f J <br /> J C_"-,r / fII�{.oKr/l�•�I ! <br /> Physical Address �/1 - I �a��2 T-( i� <br /> �J J Inspection Date lo / I / <br /> l <br /> Time In Time Out <br /> Business Rep Q AM O AM <br /> C-1 Title /q <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 Q Active <br /> Q Passenger g Q Generator Q Outdoor <br /> GPS Latitude O ® Closed Q Altered <br /> Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® Trucking Fleet Q Government etreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection j0 Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shred �/ Q Other <br /> 6V <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 Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q 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 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years 31 <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> f <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> t�In,Compliance-No Violations j <br /> Q Q Other:§ <br /> Comments z <br /> Inspection Form Included: Q / <br /> Comments Included: �— �_iness�Rp�'sSign �BuPhoneNumber nspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct °h t c E X A M P L E 11 <br /> 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />