Laserfiche WebLink
Waste Tire Su. ✓ey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California 11 - 1196698 <br /> calRecycle 181(Rev.Recovery <br /> 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- , 5 1 s 0 1 Inspection Type(Fill one) <br /> Site Suffix: * Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier oCHP oCalRecycle 0 Complaint oEducational Visit 0Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> -7 3`A av e- <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title 0 AM I &AM <br /> lJ J C> QPM I � 2 QPM <br /> �c��,;. '�. c�ct.�w.a,n �C <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 /> Active 0 Passenger • Generator 0 Outdoor <br /> O 0 Closed 0 Altered 'VI� <br /> GPS Latitude <br /> O 0 Inactive Q Truck 0 Hauler 0 Indoor <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 6 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 /> 0 Notice Of Violation 0 Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m m m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or Ex►7 <br /> a <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 2 <br /> W <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance-No Violations o <br /> O 1 0 Other:§ <br /> Comments `w \ <br /> �in�_ �•2.. o��ujav�G sass,S��O�_e <br /> N)to <br /> Inspection Form Included: 0 <br /> Comments Included. <br /> Business Rep's Signature Phone Number Insp ctor's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: X7*:V:]l EIXIAIMIPI LJEJ 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />