Laserfiche WebLink
Waste Tire Su, vey & Inspection Repon Inspection Report Number <br /> Cal Rec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Sur� y Form - Page 1 I1 1196464 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> less Profile Inspection Details <br /> I r1D ' -72 _ O ` Inspection Type(Fill one) <br /> Site Suffix: ` 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ��� 00.9 �� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name IF <br /> Inspected By Inspector <br /> 1 <br /> Physical Address <br /> �� aszo6 Inspection Date 1 IJ / I / 1 3 <br /> Time In Time Out <br /> Business Rep Title 1 AM G 0 AM <br /> ^ ` 0PM d J [QPM <br /> eche 1nc� `?J�S� �c�c�o� <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 /> T 0 Active 0 Pas� ger 0 Generator 0 Outdo r <br /> ° I' Closed 0 AAeFed Nr� (v <br /> GPS Latitude 0 Hauler 0 Ind or <br /> ° 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> " 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 �•jVv�(M V�� C2h <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / Ffl <br /> / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators .In Compliance-No Violations o <br /> 0 0 Other:§ _ - <br /> - z <br /> 6 <br /> Comment Ms <br /> ["pection Form Included: 0 <br /> Comments Included: 0Lf O l <br /> Business eWs Signature Phone Number AInspeor's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: X* V EXAMPLE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />