Laserfiche WebLink
. .......... <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California <br /> CalRecycle 181(Rev.10/10) 11 - 1210539 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 <br /> A-Survey BLUE OR BLACK INK PEN <br /> ness Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: -A ck - 01 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If <br /> f0 xReferral,choose referral type(Fill one) <br /> Identifier: ;Ck-V\ '7001%S�V\ z. CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> ' ' co <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 0 <br /> 10322 Ut,V\r,e- 9-A <br /> (A 9 5 37 Inspection Date g 2 6 t 3 <br /> Time In Time Out <br /> Business Rep Title � ) 0 AM S OAM <br /> 0 PM PM <br /> t 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 /> 9� 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> GPS Latitude 0 40 Closed 0 Altered 0 Hauler 0 indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude 0 Planned 0 OTR 0 End-Use 0 Container <br /> -iness Type(Fill all that apply) <br /> Jew Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 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 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§429 ` Compliance Deadline <br /> 0 0 PRC§429 C>vxe— Ck0SQ_0-zV 0 N <br /> 0 0 14 CCR§- C' TQZ uirements Date <br /> 0 0 14 CCR§- m / m / 3 <br /> 0 0 14 CCR§ ays <br /> (Required for NOV or EXT) �p <br /> lC� <br /> 0 0 14 CCR§ F <br /> 0 0 14 CCR§ :e Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 2 <br /> UA <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance-No Violations <br /> 0 0 Other: <br /> Comments <br /> %v)- \A <br /> -AT twel-c, � <br /> Inspection Form Included: 0 <br /> Number 1 71n spec r's <br /> 0 <br /> 0 <br /> Comments Included: <br /> BJ,�es.R Phone NSignature Phone Number <br /> INSTRUCTIONS ON BACK [C:omre�cto Incorrect: X EXAMPLE 1 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />