Laserfiche WebLink
Waste Tire Skey & Inspection Repor ., Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1255831 <br /> CalRecycle 181(Rev.y(Cal 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- Inspection- Q ` Inspection Type(Fill one) <br /> Site Suffix: o 1 . Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Scxy\ 1,00- v�� /lam_ / Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facilit(ry�-Name \ ` _ Inspected By Inspector <br /> Physical Addre o:�> L G <br /> - , O M16\ T 7 U <br /> Inspection Date O 1 / 2- 6 / I 6 <br /> S ko Gk-�o V\ t gS215 1 <br /> Time In Time Out <br /> Business Rep3&,,pn Title �yj A ` O AM c AM <br /> WMA T~- 1 0 PM "1 O O O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> ' <br /> Tire Count(Whole/PTE) I ' (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 9 Active &Passenger 0 Generator 9 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler e Indoor <br /> D Q Inactive i Truck <br /> Longitude - Q Planned Q OTR Q End-Use i 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 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 /> 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 I <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle Z ! <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXTJ <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 Q In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments 2_ kl VNC_ ((Pax� V4'e__ 0.6y�P_ flh. <br /> ('_Nr, � <br /> Inspection Form Included: <br /> Comments Included: <br /> Bus ness Rep's Signature Phone Number Inspector Signature__4�7 Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK [Correct:0 Incorrect: X EXAM L E 2 11 <br /> 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop :LE <br />