Laserfiche WebLink
I <br /> Waste Tire 3u. #jey & Inspection Rertspection Report Number <br /> calRec cle State of California T a <br /> Y CalRecycle 181(Rev.10/10) C rP9/®�// ®�V1'f ��l�e 11 1255711 <br /> Dept of Resources Recycling and Recovery(CalRecycle) MJ IJ V e A CSA <br /> Part A-Survey BLUE_ OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- r I / I _ _ o Inspection Type(Fill one) <br /> Site suffix: 10 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. Irl U tN Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address J �. o CA <br /> V <br /> ��C�.C�- �� ���� ,r Inspection Date � I / �,: -5 / <br /> J G� Time In Time Out <br /> Business Rep Title M 0 AM <br /> O PM ® 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 /> ` • Active Q Passenger a Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> G+P� Latitude Q Hauler Q Indoor <br /> o Q Inactive 0 Truck <br /> Longitude — Q End-Use Q Container <br /> Q Planned OTR <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 �(JIy urine_ Oct.PiU puj - <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS 11 <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 /> Q Q 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 EXT) N <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 /> w <br /> Q O 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 <br /> Inspection Form Included: O <br /> Comments Included: <br /> Business Rep's'Signature Phone Number Inspe is Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect: R*Y]IEIXIAIMIPILIEI 11 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />