Laserfiche WebLink
Waste Tire SAkey & Inspection Repor► , Inspection Report NumberState of <br /> ■ <br /> CalRecycle CalRecyclel'fornia 181(Rev.10/10) <br /> Survey Form - Page 1 I1 - 1196673 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection� -7 _L � � - O ` Inspection Type(Fill one) <br /> Site Suffix: 1 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: J O^Q �/ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name \ ` , InspectedBy Inspector <br /> M �OA� � <br /> � 0 �cC. q - o ��T k'.)Physical Address <br /> 55 5 lv• Maas <br /> ma'y'keCol- Inspection Date I 1 / 2 6 ' 3 <br /> qS3� <br /> Time In Time Out <br /> Business Rep Title O AN1 �PM <br /> M' 7' % V 40 PM <br /> ('. <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 /> 40 Active • Passenger 0 Generator * Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> . 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 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 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 <br /> 0 <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 1 Q 1 Other:§ <br /> Comments ���rcl 0x\ X)[� ay\ xmk Q <br /> o <br /> Inspection Form Included: Q _ q <br /> Comments Included: � - " -g -" `, I <br /> Business Rep's Signature Phone Number Inspec or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: g jEjX�AjMjPjLjEj 11 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />