Laserfiche WebLink
0 Waste Tire Survey & Inspection Report -Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 1196545 <br /> CalRecycle 181(Rev.10/10) 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- Inspection Type(Fill one) <br /> Site Suffix: ( (� 6 Routine Q Re-inspection Q Referral Q Observation <br /> LocalJ_ If Referral,choose referral type(Fill one) <br /> Identifier. SaM dam+, co CO V` Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name _` / Inspected By Inspector <br /> l? V_e_ -rVnG. 3 qr - , 0 1 v <br /> Physical Add ss <br /> I73oo Ja�,.ov - Ra- <br /> C ` 5227 Inspection Date / Q 3 / 3 <br /> i ��vu�eJn�S C� <br /> Time In Time Out <br /> Business Rep Title *AM ` c O AM <br /> F � ® ' S S 0P 1� 2 Q J 0P <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 /> 0 Active Q Passenger 40 Generator 0 Outdoor <br /> Q Closed Q Altered <br /> CaP� Latitude Q Hauler Q Indoor <br /> 0 Q Inactive 0 Truck <br /> Longitude — Q Planned 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 p <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 0 Other AS `ao�41�C�t O <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 O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date 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 Exp N <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 /> Comments r+ <br /> o\ cp� .�E t.J11E �Q '.��.�P�Gdv. � � •S c <br /> Inspection Form Included. Qy �Oq—y6g <br /> Comments Included. Me <br /> B iness Re Signature Phone Number Inspecto s Sig at Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: 7x*:q:lIEIXIAIMIPILIEI 1112 33 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />