Laserfiche WebLink
Waste Tire Sul iey & Inspection Report ,ispection Report Number <br /> State of Callfornia <br /> CalRecycle <br /> CalRecycle 181(Rev.10/10) Survey Form - gage 1 11 - 1177653 <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 C _7 Cj - O ' Inspection Type(Fill one) <br /> Site Suffix: J J 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 5CL�1 J0 V V Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> r st� c6.%_1> 7 q - o <br /> Physical Address M a k <br /> Inspection Date -3 / � � / <br /> OV1av1 e�� C 533 6 <br /> Time In Time Out <br /> Business Rep Title 0 AM S 0 AM <br /> 2 � O 0 PM , o I � PM <br /> Ij t 14rjlcov^b %vks M r• <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 Active S Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 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 0 Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body 0 Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q O 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 O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) n <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years c <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> f <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance-No Violations o <br /> Q Q Other:§ <br /> ` - a <br /> Comments P-10 V �i n W(;!S k-,c-2 : V-% ��pV1 A�V\ <br /> c�.cx-V e- o,v%_2N- 0,% �:oA�o <br /> C!)r Arens o� co v-.cexrL <br /> Inspection Form Included: qq <br /> Q <br /> Comments Included: • - - � <br /> Busin ss Rep's Signature Phone Number Inspe tor's Signature - Phone Number <br /> Businiss <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect: jEjXjAM PjLjEj 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LFA <br />