Laserfiche WebLink
Waste I ..a S,.,vey & Inspection F. , ori< Inspection Report NumberState of <br /> ■ <br /> CalRecycle CalRecyclel'ornia <br /> 181(Rev.10/10) I1 - 1- 17 6 7 9 2 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Su rvey Form - Page 1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: ` 3 6 -� 6 - 1 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: n �� � � Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name n � Inspected By Inspector <br /> r <br /> Physiccalal Address <br /> Inspection Date 3 <br /> �Tc7�c� �>'_�3`T7 1 <br /> l <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 0 PM go 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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> Al O Closed Q Altered A ��� /l14 <br /> GPS Latitude 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 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 0 Other A A <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 O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> a <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> LU <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> Inspection Form�nc <br /> ncluded: Q <br /> Comments luded: 0 i <br /> _ Business Rep's Signature Phone Number ns 4Si atre Phone Number <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect: E E ll 1213 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink op ® ■ <br />