Laserfiche WebLink
Waste Tire Su. vey & Inspection Report Inspection Report Number ■ <br /> CalRec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1196636 <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: 1 6_7g `(� L ® Routine Q Re-inspection Q Referral Q Observation <br /> Local C ^ If Referral,choose referral type(Fill one) <br /> Identifier: �'(�` Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address OL ( /iIII d <br /> Inspection Date <br /> (tet t 6(5o1Qs l <br /> Time In Time Out <br /> Business Rep Tile O AM 2 ! O AM <br /> 3 ' 1 J ® PM J V ® PM <br /> Ahs 16o -- <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) l 'S_ (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active * Passenger ®Generator 10 Outdoor <br /> O Q Closed Q Altered <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 /> New Tire Dealer & Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 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 FENFORCEIVIENT 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 Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) <br /> a <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 /> 2 <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ W <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q 1 Q 1 Other:§ <br /> Comments c /' <br /> OVVI Y% <br /> Inspection Form Included: O �o2 <br /> Comments Included: (0 <br /> Bus p's Signature Phone Number ns /anature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: jEj'�jAj0jLjEj 11 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />