Laserfiche WebLink
Waste Tire Su,vey & Inspection Report c Inspection Repor: Number ■ <br /> Cal Rec cle State of California — <br /> Y CalRecycle 181(Rev.10/10) I1 1230398 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 <br /> )art A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � n � ® ` Inspection Type(Fill one) <br /> Site Suffix: ` J / "', 1 Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: 501V11 11' ,Q rJ;� Q-0 I Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> Inspection Date 6 Q <br /> Time In Time Out <br /> Business Rep i Title 0 AM <br /> O 5 .PM 2 S A PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) Q M (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 ' _i L.J 4&Active Q Passenger 0 Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned 0 OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) M1p, <br /> • New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreacier 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 0 Other <br /> MC40 Som <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 EXl) N <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 /> 2 <br /> W <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators .In Compliance-No Violations o <br /> Q Q Other:§ \, 1 <br /> Comments rj � .� Q. � �(�2. •. _ _ ,s_ �\ � � .� '�C Q1rl(J� <br /> �� . <br /> waS VN0k91 ` <br /> Inspection Form Included: Q l 1 Q <br /> Comments Included: zoq^`160����� <br /> Business Rep's Signature Phone Number Inspe or's Signature Phone Number <br /> �,,( 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: � NJ E X A M P I L E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA �� ■ <br />