Laserfiche WebLink
Waste Tire Sft & Inspection Re oection Report Number <br /> State of California <br /> CalRecycle - 1242399 CalRecycle 181(Rev.y(CalRecycle) Survey <br /> Survey Form - Page 1 I1 12 4 2 3 9 9 <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: ' 9 5 l Q Routine ® Re-inspection Q Referral Q Observation <br /> LocaltI If Referral,choose referral type(Fill one) <br /> Identifier: �CeL �l:�C�L �1V\ C(� Aq,,'ZQ CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> )r_> Frv_.., )A,— - l <br /> Physical Address 'r-TU4,N1 <br /> Inspection Date � / 0 (9 1 <br /> / I `j <br /> Lr'-+k'--0P CA 'i5330 <br /> Time In Time Outu7 <br /> Business Rep Title LL__ O AM 1-7 O AM <br /> �p?� C✓�D�2 S d ® PM m PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) 1 <br /> 0 ® Active Q Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude – Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ®'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 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 (Required for NOV or EXT) 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 /> 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:§ <br /> — _ z <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: ® �3 <br /> usin s R Signature Phone Number I pe o s gn ure Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: M � E X A M 1 1112131 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy,L �� ■ <br />