Laserfiche WebLink
Waste Tire Survey & Inspection Re or l nspection Report Number <br /> CalRecycle State of California <br /> 10/10) <br /> CalRecycle 181(Rev.ry(Cal Survey Form Page 1 I1 - 1255798 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) _ <br /> part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: j 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: n �Oaq u I Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address J JA1J JY1;1/L/ POW <br /> l-���► `--'" <br /> Inspection Date / 0 I <br /> � <br /> CA qS � V <br /> Time In Time Out <br /> Business Rep Title L j O AM O AM <br /> � fYRocky ' � 0 PM � 4 ® PM�_� <br /> - operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) / (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> (rp Q Active QPas enger Q Generator Q Outdoor <br /> GPS Latitude 41 Closed Q Alt red Q Hauler Q Indoor <br /> O Q Inactive Q 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 <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 /> QQ 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date FTI <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 E)(1) N <br /> a <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 /> 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:§ <br /> Comments {{.tl� �'�'� i),c11 =.1C-,r'�_ /XDic��. U✓� Y'GU�7 /-�4�� !_Y�-s�" `d'yC.� �, <br /> wuo loloei IUD v i oL"k La, o-r au-- c) <br /> T?-T-0 fZ(_ CLDSP. nua Glad a'�l vr�.lZGC�2 dia dka)u <br /> Inspection Form Included: Q <br /> Comments Included: Q --- <br /> Busi ss Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: V ��EjXjAjMjPjLjEj 1112131 <br /> 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA �� <br />