Laserfiche WebLink
M Waste Tireiey <br /> & Inspection Reps, t Inspection Report Number <br /> Cal Recycle state of calif... <br /> .(Rev. <br /> a 11 - 12 2 6 6 9 4 <br /> CalRecycle 181 Rev.10/10) �urVey 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- �'1 G - O j Inspection Type(Fill one) <br /> Site Suffix: r l a Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: S GA n _T O 6t j w i1 n CO-Lk f)�A Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility NameInspected By Inspector <br /> 'S40j/j,0 -� ej I <br /> Physical Address C3 Z <br /> Inspection Date <br /> Time In t Time Out r l <br /> Business Rep <br /> Title �1` I O AM O AM <br /> 1e l� C—_ � n b 1 � /u AWL�' O PM � � U � PM <br /> ( <br /> -- - ! - 5� - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) ("�l <br /> ' (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ® Active ® Passenger ® Generator ® Outdoor <br /> O Q Closed ® Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Truck <br /> Longitude - Q Planned ® OTR Q End-Use ® 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 <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 o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <br /> W <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators *In Compliance-No Violations o <br /> Q Q Other:§ __ z <br /> Comments k\1� lJL U1 Skc.���Q _ n �lri,n �IUL U 11 I n1 P !tip w`` a -21[0W'�1 <br /> Inspection Form Includtofa- <br /> Comments Includignature Phone Number Insp or's Signature Phone Number <br /> 62081 <br /> INSTRUCTIOect: Incorrect: E X A E 1 2 3® CalRecycle Yellow Copy:Operator Pink Coy A ■ <br />