Laserfiche WebLink
Waste Tire Su. ,rey & Inspection Repon nspection Report Number ■ <br /> CalRecycle State of California I 1 - 1210456 <br /> CalRecycle R(Rev.y(CalRecycle) Survey <br /> Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ' _ 0 Inspection Type(Fill one) <br /> Site Suffix: 1 ® Routine 0 Re-inspection Q Referral Q Observation <br /> Local �- 1 ], If Referral,choose referral type(Fill one) <br /> Identifier: S U'j'-pr1 G V11 •� Cp1�(�1 Q CHP Q CalRecycle 0 Complaint Q Educational Visit Q Other <br /> Business or Facility Name �" L <br /> Inspected By Inspector <br /> �Q_�AeA o W, )'o„c,\ '1J-�s�;�� I 3 <br /> Physical Address <br /> X3_'5 <br /> CA10'� Inspection Date <br /> Time In Time Out <br /> Business Rep y� ], Title AMO AM <br /> O.._PM � 0 Q ® 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 B Passenger ®Generator Q Outdoor <br /> O Q Closed O Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - O Planned OTR O End-Use i Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet 0 Government Q Retreader Q Dismantler 0 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 /> O O Notice Of Violation Extension <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 /> 0 Q PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CalRecycle Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> 0 0 Other:§ AA 1 <br /> Comments \ZN� ��! In ,b 1 (A a l DAA7 <br /> G <br /> civ,of-�3 Cf Ca eu,3 D-� Cm W n <br /> Inspection Form Included: 0 �I�( 1� <br /> 1 � k <br /> Comments Included: ® - n%a �a t--���" <br /> B sines Rep's Signature Phone Number InsActor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E X A PILIa 1112 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink C y: © ■ <br />