Laserfiche WebLink
Waste Tire?Cry & Inspection Repor li,spection Report Number <br /> CalRecycle State of California <br /> - 1210459Caycling le 181(Rev. y(Cal Survey Form - Page 1 I1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survev BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ` .� q n >� /1 Inspection Type(Fill one) <br /> Site Suffix: 1 I ply lJ ® Routine Q Re-inspection Q Referral Q Observation <br /> Local9 / (1 L If Referral,choose referral type(Fill one) <br /> Identifier: S� U��ut 1 l� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> rn q� r Inspected By Inspector <br /> V h f / 5 1 � � V��� V� � �1 S <br /> Physical Addres 3 - 1 v CS ��(� <br /> � <br /> Inspection Date <br /> A erg �SLbs <br /> Time In Time Out <br /> Business Repl Title O AMO AM <br /> �l � 1..�+jA mjAt1H, ® PM z 0 � 6 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 /> /0 Q Active Q Passenger Q Generator Q Outdoor <br /> PSLatitude ° #Closed Q AlterJA <br /> GdfQH�IQ Inutdo)d / <br /> o Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q 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 /> Q 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 /> Q 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 m m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> Q Q 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 /> . 0 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 ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> z <br /> Comments1 r,., 1 r �� WAS <br /> d Alv�., 0� 4hAl. 041 <br /> 1�tS 0+ Ona N <br /> -TP -b : l U`b,17 - Get T ' i S <br /> A-A,9 1 LAU , 'N tATCn tA n)jl Us T <br /> v <br /> Inspection Form Included: Q -t8[Q <br /> Comments Included: O v <br /> Business Rep's Signature Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: W 62081 <br /> E X A L 1 2 3 <br /> >s.,aa.. White Copy:CalRecycle Yellow Copy:Operator Pink Cop •L <br /> ® ■ <br />