Laserfiche WebLink
A <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> Cal Recycle State of California I 1 - 1230131 <br /> CalRecycle 181(Rev.y(CalRecycle) Survey <br /> Survey Form Page 1 <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_ ( Inspection Type(Fill one) <br /> Site Suffix: U 0 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S��1 ��pt tel/) co A, Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> 11 � <br /> �c 1VVI LA 0nt h <br /> Physical Address m v 1 �5 L01TO <br /> SSSS Ave 5 <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title ] ) 71 O AM O AM <br /> 1�l' uI-t U'y� D, • "l o ® PM 3 a ® PM <br /> � nc1 <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 Q Passenger Q Generator Q Outdoor <br /> O ® Closed Q Altere )n <br /> GPS Latitude / Q Haule"r� 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 /> 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 451 imZ2-- <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 /> 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 N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <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 /> 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 Q1 Other:§ <br /> 21 n1A <br /> Comments ,f 4 N <br /> L,3tAs nolo Na v"0 fT'v4s �Cr0-US Q+ cvnrn <br /> N oats� l, ono ,_+,1r f-g p wP_ <br /> -I, do-'e TP.zp, <br /> Inspection Form Included: Q - 4/. <br /> � — <br /> Comments Included: <br /> T46 Business Rep's Signature Phone Number Insp tor's Signature Z Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: NJ E X A LIX 1112 31 <br /> 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink A - <br /> L ® 0 <br />