Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1244955 <br /> CalRecycle 181(Rev. (CalRecycle) <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- � _ O � Inspection Type(Fill one) <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local /' If Referral,choose referral type(Fill one) <br /> Identifier: San ()U/,I wf-N (OAA-1 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name " I Inspected By Inspector <br /> 51% 60 ayt " ���r m of i nt" C� u P S _ 10 1 ES Coll <br /> Physical Address <br /> 11530 �j . Ci V� Milc. <br /> Inspection Date / v <br /> 2L✓(�TIJn �[f <br /> Time In Time Out <br /> Business Rep TitleI O AM u O AM <br /> V Q PM ( 1 � P PM <br /> Operational Status Tire Type Business Role Storage Type <br /> — <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q F s/lenger Q Gen at�tpr1, Q Ou door, <br /> D @ Closed Q Altefel" <br /> GPS Latitude <br /> 0 Q Inactive Q Truck Q Hauler Q Indoor <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 m R/I Ap, <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 /> 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 EXE <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 /> 010 1 Other:§L ,�•, 1 <br /> Comments <br /> IcAiA1 <br /> i <br /> Uv <br /> l� m) u u'i,-\ '6' LL)ASQ'NaWo, Cao q s. Clo:�,e T IPZ <br /> Inspection Form Included: Q pm <br /> Jb' CZ>,g)'�c� <br /> Comments Included: Q <br /> Bus `_ / <br /> ine s Rep' Signature Phone Number Ins tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK r� orrect:0Incorrect: EXAMPLE 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © 0 <br />