Laserfiche WebLink
Waste Tire Su. vey & Inspection Repori Inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1255838 <br /> CalRecycle 181(Rev. (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 Type(Fill one) <br /> Site Suffix: ' 0 1 1 8 I O Routine 0 Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: uh O CHP O CalRecycle Q Complaint O Educational Visit O Other <br /> Business <br /> ` tor\Facility Name C Inspected By Inspector <br /> w � �� � d� �� _ <br /> Physical Address C� 1 O A/I v <br /> Inspection Date /\ 2 � 2 <br /> Time In v Time Out <br /> Business Rep \\ Title < I-0L v 0 AM 0 AM <br /> •PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> O-32 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> • Active 0 Passenger 0 Generator 0 Outdoor <br /> O Q Closed O Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O Q Inactive * Truck <br /> Longitude - Q Planned Q OTR O End-Use , 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 /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> O O 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 In Compliance-No Violations o <br /> 0 Other:§ <br /> CommentskkA Ai�e - o1aw <br /> boc's� <br /> Inspection Form Included: . <br /> Comments Included: 'moo-JZ�� <br /> B ss Rep's Sig ure9ePhone Number Insp for s Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON B K Fcorrect:o Incorrect: E X A M P L E 11 12L3] <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy L <br /> ■ <br />