Laserfiche WebLink
t <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1245043 <br /> CalRecycle lndRec(Rev. <br /> very( al 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- '7 L 1 Inspection Type(Fill one) <br /> Site Suffix: 1 L l 3 v i e Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Cl,Y' � co, Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Lc�ynw�a�n Inspected By Inspector <br /> /�o�•Aes �c�s `�,�c Ca��;�c, �. 7s5 Q _ © � <br /> MAT 1 V <br /> Physical Address <br /> p q 536 Inspection Date 2- 1' / 1 S <br /> Time In tJ Time Out <br /> Business Rep ` Title Z O AMO AM <br /> 6n O 0 PM _5 4k 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 Q Passenger Q Generator Q Outdoor <br /> O 0 Closed Q Altered !� 4V/ <br /> GPS Latitude /%t Q Hauler 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 0 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 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 EXE 04 <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 /> Comment <br /> 0. ,�`I_�— 1, <br /> Inspection Form Included: 0� , . 701 V�3Z2 <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspe tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK [Correct.* Incorrect: ( E X A M P L E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />