Laserfiche WebLink
Waste Tire Sup grey & Inspection Report Inspection Report Number <br /> CalRec cle State of California — <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1244945 <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 � � � � � O 1 Inspection Type(Fill one) <br /> Site Suffix: l I 'Routine 0 Re-inspection 0 Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SAS J04 LA �(\ 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Businessor Facility Name eT Inspected By Inspector <br /> l,e>~► �l e� \ 1 fie, _ <br /> Physical Address J o CS � <br /> -1 <br /> s-n t Inspection Date 1 / JL <br /> (p `J <br /> J . Time In Time Out <br /> Business Rep 10 AM <br /> \,, C Title >� �'1 ` O 10 AM ` � � O <br /> r 1 Ugm V Q PM 0 PM <br /> 1 <br /> �Cyr1 S S Sk v J c. (`t` c!' <br /> - -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' ®Active 41 Passenger ® Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer •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 /> ® Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation � 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 /> 00 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0. 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or Exp N <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 /> 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 /> 0 0 Other:§ <br /> Comments e, �1S ` <br /> �i Jc, i 1 V <br /> Inspection Form Included: 0 �G� ;`[J �a/'rC`� A, <br /> ^� T q 'fir 1 <br /> Comments Included: <br /> B ness Rep's Signature Phone Number Inspe is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: :X*�] E I X I A IM P L 1 273 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy. ® 0 <br />