Laserfiche WebLink
Waste Tire SL%ey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1230171 <br /> ry <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- 7 Insptition Type(Fill one) <br /> Site Suffix: t / 1 3 O I Iq'ou{ine 0 Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S Y-' ✓\ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> L <br /> Physical Address 7ChW l q - 1 Q 1 MATT U <br /> 3 554 Vz'. 'aa \W-4r- Lo.-A e- <br /> Inspection Date <br /> ��Z l2 <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 0 PM S 1110 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Who <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> /PT <br /> .0 Active 0 Passenger 0 Generator Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned 0 OTR 0 End-Use 0 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 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 /> Q Notice Of Violation Q Extension <br /> Q Q <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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date 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 EXT) 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 Z <br /> Q 1 Q 1 Other:§ <br /> Comments fJ_ i01/� O�r�� Or1n•5 Tkne- C��S 1(�O <br /> c� - a=ONONSC- <br /> Inspection Form Included: Q r t 1-I s"2 N�3 �� 20 �-32S I <br /> Comments Included: Q- U <br /> usiness Rep's Signature Phone Number �Inspe onature Phone Number <br /> INSTRUCTIONS ON BACK [Correct: Incorrect: E X A M P L E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LFA <br />