Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 1176756 <br /> CalRecycle 181(Rev. (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 /> _ Inspection Type(Fill one) <br /> 01[e Suffix: © ­7 l i® Routine Q Re-inspection Q Referral Q Observation <br /> Locall _ If Referral,choose referral type(Fill one) <br /> Identifier: �C�Y` �C)U�✓�1 �G�-� 0 CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ` Inspected By Inspector <br /> ALVyt � �►1C�ts� '�ct,r�i s �r. � � - t U l �rv(.6& ' <br /> Physical Address <br /> 02�'©88 �-c�'L� -T•i-ems �'►� , <br /> Inspection Date "o, 1 I I <br /> CA q53o20 <br /> l l l <br /> Time In Time Out <br /> Business Rep Title ® AM ®AM <br /> t o Q PM O 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 /> 3 ' Q Active Q Passenger ® Generator Q Outdoor <br /> 0 Al JA d/A <br /> GPS Latitude ® Closed Q Altered O Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - O Planned Q 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 /> Jsed Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q 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 /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> OO 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date Ffl / M / M <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> O O 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 /> 2 <br /> Q Q 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 <br /> in Compliance-No Violations o <br /> O O Other:§ / <br /> Comments �yl� y�.r�-{�,y� �- ,(� it) V►r:��^� . �, <br /> l <br /> �rQ(�c; C� !,14 zzn-n( S_z1�it-c:J /�l�ifC S }� h4-f3 cS` eftc-C�!M-Z Cl r­ <br /> Ado <br /> Cr�ld P- Ado74—A)-C-- �ny1 Cy tiM- � L-J2'_✓'� <br /> •-�-,�►� _.��..-� �- /vim 0.3 3 7 �- c lc ��� <br /> A <br /> ection Form Included: Q <br /> Comments Included: Q-- <br /> Business Rep's Signature Phone Number_ n Si nature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK �CorrectAb Incorrect: X E X rA P L E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />