Laserfiche WebLink
■ inspection Report Number <br /> Waste Tire Su. ,iey & Inspection Report i <br /> State of California <br /> CalRecycle I 1 - 1210 419 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <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- q I r� - ,per Inspection Type(Fill one) <br /> Site Suffix: J of .7 4 J v 1* Routine Q Re-inspection Q Referral Q Observation <br /> Locall ���� - If Referral,choose referral type(Fill one) <br /> Identifier: S05l'� �J V0 n Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address Q ) Cs�o��o <br /> 5 C l E �N <br /> Inspection Date <br /> ���n(,� C�Mp CA Ism) <br /> Time In Time Out <br /> Business Rep � h� Title � C O AM �7 0 AM <br /> `7fC A �SU(��J� \'(1(�' C� J ® PM J *PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) 3 <br /> ® Active Q Passenger ® Generator ® Outdoor <br /> GPS Latitude 0 Closed Q Altered <br /> Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned ® 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 9 Other �C_kvt tv; i2 I <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 N <br /> Q IQ 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 /> 010 1 Other:§ l <br /> Comments <br /> (Lo � `K 1 I 1.n� ?Or axa� lk�G 0",)(� <br /> N O Ut D l(J1 i on,5 01 wo_6� c. p(A.,r n <br /> Inspection Form Included: <br /> Comments Included: <br /> __ 1 C1�,9 �l 31'7$ <br /> Busi ess Rep's Signature Phone Number Insp tor's Signature Phone Number <br /> �,( 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X NJ E X I A 1112131 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop L ® ■ <br />