Laserfiche WebLink
41 <br /> Waste Tire S.., vey & Inspection Repor ,, Inspection Report Number ■ <br /> ealBecycle State of California 11 - 1255753 <br /> CalRecycle 181(Rev. (Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> 'art A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � Inspection Type(Fill one) <br /> �Site Suffix: r / d I f ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �/'1/3flY���y��L Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name C t <br /> Inspected By Inspector <br /> 1/" , Cal Aa.__ �li��cc.� C-1/ _ C) / <br /> Physical Addre� <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title ( 0 AM 0 AM <br /> (ovk Yrll 1 1� 17(.i�I�t) 1 / 0 PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ' D� / (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> tv ® Active ® Passenger e Generator ® Outdoor <br /> O Q Closed O Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned 0 OTR Q End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet ! 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 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 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Requited for NOV or EXE N <br /> r <br /> a <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 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 <br /> Q Q Other:§ - <br /> Comments ail / kL41z0_L_-' C ""/2 <br /> u (d 116w� arm kzd bol <br /> Inspection Form Included: Q <br /> 744 <br /> Comments Included: 0SO 1 <br /> B sines,R s Signature Phone Number Inspect s Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: M � I E X A M P L E 1 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ■ <br />