Laserfiche WebLink
Waste Tire f9ey & Inspection Re o"Inspection Report Number <br /> CalRecycle State of California _ _ <br /> CalRecycle 161(Rev.y(Cal Survey Form Page 1 I1 1242541 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- t-i c Q (j Inspection Type(Fill one) <br /> Site Suffix: T J I Q fI r) a Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: set C) J oa,P.u'IrN r�kk'-)t Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name _I Inspected By Inspector <br /> Physical Address <br /> / <br /> CA SUS Inspection Date <br /> O� Time In Time Out <br /> Business Rep - 9 Title O AM r� O AM <br /> � • O 0 * PM �� J D a 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 ® Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler A Indoor <br /> O Q Inactive • Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ®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 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 /> 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / 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 E?C� <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years ul <br /> F <br /> Q Q 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 Q Other:§ <br /> Comments Qa,,kx� Wk�1c.- i�e i�-)��i <br /> Inspection Form Included: Q <br /> Comments Included: <br /> B sii ess Rep's Signat re Phone Number Inspec is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: � E X A M E L 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co y: EA <br />