Laserfiche WebLink
2 Waste Tire Sui iey & Inspection Report nspection Report Number <br /> Cal Recycle State of California — <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 11 1229937 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey <br /> _ BLU_ E OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I -7 n 1 Inspection Type(Fill one) <br /> Site Suffix: 2 L 1 ' 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. �� V`y Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Q :Y2,- 'Z <br /> Physical Address <br /> r Inspection Date 02- / O / f S <br /> ���� Time In Time Out <br /> Business Rep Title O AM O AM <br /> 0 PM e 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 /> (2J Q Active Q Passenger Q <br /> Generator Q Outdoor <br /> FSLatitude Closed Altered, Ata A <br /> GQTrr Q Hauler Q Indoor <br /> O Q Inactive uck <br /> Longitude - Q Planned Q OTR o 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 ma %Vk-_ -7-wses'\) C.-e <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 / mM <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> r <br /> Q Q 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 /> 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 /> rrCommentsh <br /> -t-�� %� <br /> _�'c�'• Q��.-�- `��c-c,S ��� \t�cce�' •Y� bvS� nes vs� <br /> ss �-e Flo <br /> WN <br /> Inspection Form Included: Q <br /> Comments Included: Q r <br /> Business Rep's Signature Phone Number Inspector' Signature Phone Number <br /> INSTRUCTIONS ON BACK [Correct:I. Incorrect: �j EXAMPLE 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />