Laserfiche WebLink
Waste Tire Sur ve & Inspection Re oronspection Report Number <br /> CalRecycle y p _ p _ <br /> State of California I 1 1242297 <br /> CalRecycle 181(Rev.y(Cal Survey 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 r- Q Inspection Type(Fill one) <br /> Site Suffix: `� '* Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: S ,o,—Jom(,(�1 C0LvN Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> N CJ110nu l Co� e.11G'l� Cu tt n, 3 g - 1 0 <br /> Physical Address Es CQ-rTO <br /> Pti (��u 6 _ l�ulcr�oD <br /> Inspection Date <br /> S�d �or` G14 5Sz1 S <br /> Time In Time Out <br /> Business Rep i 1 L Title + O AM O AM <br /> �flU` SLS 12.'EC.G� m N.f�LI� pJ- 1 3 C) 9 PM � � V ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (� <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> '� <br /> ® Active ® Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS 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 -G On <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 EXE <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 /> 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 Q Other:§ ,,, 1- <br /> Comments <br /> LAM c\g� LAS/A 6—AL �'1°J� � 10 1 ( neo r)n�V li S CAomlc, C(.rlj <br /> 0 \k O3 a1; 113 U,A aej <br /> Inspection Form Included: Q G^ <br /> Comments Include �o _ <br /> Busl ess Rep',-Signature Phone Number Ins tors Signature Phone Number <br /> INSTRUCTIONS ON BACK Corre�ct,* Incorrect: E X A M P ,L E 1 2 3 62os1 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop .LE <br />