Laserfiche WebLink
Waste Tire Survey & Inspection Repo Inspection Report Number <br /> cal Recycle State of cle181(R 11 - 11767u9 <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- Inspection Type(Fill one) <br /> Site Suffix: ' Lt 1 ® 44 (75- i# Routine Q Re-inspection Q Referral Q Observation <br /> Local /_ If Referral,choose referral type(Fill one) <br /> Identifier: �,t 5or�c6�tit �tNt,r-� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address - <br /> � 6.11� <br /> _ Inspection Date <br /> eA <br /> Time In Time Out <br /> Business Rep Title �J C) AM p- &AM <br /> O PM � � � �.7 ? 0 PM <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 0 Generator Q Outdoor <br /> D Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 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 0 Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 0 Other `T G <br /> ---- <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 Q 0 Notice Of Violation 0 Extension <br /> 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 I <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from Call <br /> Q Q 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 o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> f <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 <br /> �.In Compliance-No Violations <br /> Q Q Other:§ - <br /> Comments `z <br /> f <br /> Inspection Form Included: Q <br /> Comments Included: = — `?� `/ -C'2 - ` -A <br /> Business Rep's Signature Phone Number ctoKpfgnature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X E X A P E 2 3 <br /> - -- - - <br /> White Copy:CalRececycle Yellow Copy:Operator Pink Copy:(L4--,**' <br />