Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1230126 <br /> CalRecycle 181(Rev. (Ca[ Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- SurveyBLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: u 0 40 Routine Q Re-inspection Q Referral Q Observation <br /> Local — a If Referral,choose referral type(Fill one) <br /> Identifier: stn U 0 al LAL t t�� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Addr6o <br /> raInspection Date S S <br /> � cJv �/� 9S3o� <br /> Time In Time Out ),� <br /> Business Rep Title 0 AM PM I � "` 5- 0 PM <br /> .Ttn o'. CGt r\ i 0 0 !Y--J-69fort_ <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) /X (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q <br /> PassQ GII�eVnIerator Q Outdoor <br /> it <br /> OS Closed <br /> GPS Latitude O Q Inactive Q Truck Haule4 Q ddrq <br /> Longitude - Q Planned O OTR O End-Use O 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 ® Other 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 0 Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> OO 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date F11 / m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> 0 O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 0 O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance No Violations <br /> Q 1 O 1 Other:§ <br /> Comments ► <br /> �� G�O�J1x-ten- <br /> CA UnTR„�aM i6A1l l LA)Z4�Ie�'[,'r� S l��(lw�� �IMR "fL <br /> d <br /> Inspection Form Included: Q LA <br /> Comments Included: Q , Q <br /> Business Rep's Signature Phone Number Insp or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct* Incorrect: JEJXJA LLEI 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink C y: ® ■ <br />