Laserfiche WebLink
Waste Tire S,. vey & Inspection Repor. Inspection Report Number ■ <br /> Cal Rec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 - 1226697 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- i C 5 - Q Inspection Type(Fill one) <br /> Site Suffix: L J 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q f t(�uj (> (01k 1klt\ O CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physicalldress I���� Inspection Date 1 � / Q y <br /> Time In Time Out <br /> Business Rep Title 0 r O AM 0 AM <br /> ® PM 5 Q • PM <br /> V <br /> 3ooN4S &('\AAhVJj ower- - <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) -1 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 a Active ® Passenger 0 Generator Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive 9 Truck <br /> Longitude - Q Planned OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <br /> * New Tire Dealer • Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 16 Used Tire Dealer Q Auto Body Q 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 /> - O Notice Of Violation Q Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) n <br /> O Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> W <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators *in Compliance-No Violations o <br /> O O Other:§ <br /> Comments <br /> G S oo�Ca'- <br /> No <br /> Inspection Form Included: ow e <br /> Comments Inclu d: — ------ -- - - - 0 1 <br /> usiness Rep's Signature Phone Number Inspe t is Signature Phone Number <br /> — -- -- _ 62081 <br /> INSTRUCTIO N BACK Correct:48 Incorrect: E I X A M I E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LE © ■ <br />