Laserfiche WebLink
Waste Tire S ulrvey & Inspection Report .nspection Report Number <br /> CalRecycle State of California 11 - 1177895 <br /> CalRecycle 181(Rev. (CO) Survey Form - Rage 1 <br /> Dept.of Resources Recycling and Recovery(CaRecycle) <br /> l <br /> Part A-Survey BLUE OR BLACK_ INK PEN <br /> Business Profile Inspection Details <br /> TPID- O q O Inspection Type(Fill one) <br /> Site Suffix: ® Routine O Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 5 LA,;n CoU�,��► Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Addr � 3 <br /> 1- Inspection Date / 0 3 / <br /> uc�'L'c On C �lS�b�O v <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> * PM 3 3 PM <br /> r) Ji�1 h C�WneI' <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 /> ' Q Active Q Passenger Q Generator Q Outdoor <br /> O ® Closed Q Altered]A N/A N f q <br /> G�� Latitude 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 Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other mo�j f, sC11Vtl C,. <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 /> Q Q <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 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 N <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 <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CalRecycle Enforcement <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 In Compliance-No Violations o <br /> Q 1 Q 1 Other:§ <br /> Comments � T117 �V I 1 1.U4 N <br /> �= u <br /> No J;0�6 'r a QvkI4b (4 r an(vn , <br /> j1s o b �_t)_n �1 i�L11,�a floss Gt�f 1� C��Un . <br /> gU�S�S Y�M <br /> Inspection Form Included: Q ' <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspet is Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect: EXAM L E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy L ® ■ <br />