Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of CaliforniaCalRecy11 - 1242245 <br /> Dept.of Resources Recycling cand Recovery(CalRecycle) Survey Form — Page 1 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � ` Inspection Type(Fill one) <br /> ' � � O <br /> Site Suffix: 1 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 1 Q.Y-\ �3eq Q V�,� CO�y% Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name �b Inspected By Inspector <br /> Physical Address <br /> Inspection Date O C7 <br /> 1 CJS cA53 D <br /> - / Time In Time Out <br /> Business Rep Title O AM O AM <br /> 1 2 d s PM I ' S (0 0 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 /> Q Active QPass�ger Q Generator Q Outdoor <br /> O 0 Closed Q Altered Ilk <br /> I , <br /> GPS Latitude Q N IQ�do1oY <br /> 0 Q Inactive Q Truck <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 40 Otherg;a�y�L, <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 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 EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 /> z <br /> Comments• <br /> Inspection Form Included: Q <br /> Comments Included: 9 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:IS Incorrect: EXAMPLE 1 2 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />