Laserfiche WebLink
Waste Tire S-, ✓ey & Inspection Repor, Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1176472 <br /> CalRecycle 181(Rev.y(Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Pant A-Survey BLUE OR BLACK INK PEN <br /> iness Profile Inspection Details <br /> Inspection Type(Fill one) <br /> Site Suffix: e1 7 I a Routine Q Re-inspection Q Referral Q Observation <br /> Local ! If Referral,choose referral type(Fill one) <br /> Identifier: Sa VA Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical- r[''' )A•�d/ddress /) ) ,0 /�,,1ry�bv(� <br /> Inspection Date <br /> S, +oc-4cyt C1 17526 <br /> Time In Time Out <br /> Business Rep Title 10 AM l 0 AM <br /> t a 4 O Q PM ` ( D 0 PM <br /> 62%ne lk-o G eS �e_J_ � <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) f <br /> Q Active Q Passenger ® Generator Q Outdoor <br /> d <br /> O ® Closed Q Altered/� <br /> GPS Latitude <br /> O 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 /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 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 Ae,_,,112�ertflr✓�( C � <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 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 Q Other:§ <br /> Comments <br /> 6M mewN <br /> ,,ection Form Included: -� �(1 t✓ �j 7 <br /> Comments Included: eignature <br /> Bu iess Rep's gnature Phon Number s oPhone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E I X P I L E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />