Laserfiche WebLink
- -- '---- _ ';:�,-�� 1� , <br /> ------------------------ <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California <br /> CalRecycle 181(Rev.10110) 11 - 1176697 <br /> Dept of Resources Recycling and Recovery(CalRecycle) BLUE <br /> Form - Page 1 BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: 0 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: Saj-�'_SOZ4 W1 n COUILYA�� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> 6 a&C-/e. 6 o(A S�a� <br /> Physical Address 3 <br /> ct Inspection Date <br /> Time In Time Out <br /> Business Rep Title i h AM O Am <br /> PM QPM <br /> �rxkA_rN <br /> Operational Status Tire Type <br /> Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) 0 <br /> Active 40 Passenger 41 Generator Outdoor <br /> O 0 Closed 'i 0 Altered 0 Hauler 16 Indoor <br /> GPS Latitude 0 inactive 0 Truck <br /> 0 <br /> Longitude 0 Planned 0 OTR 0 End-use 0 container <br /> Business Type(Fill all that apply) <br /> Trucking m � ,i 0 Dismantler 0 Tire Derived Fuel <br /> 0 New Tire 11 aaler 0 Auto Repair 0 Fleet 0 G !1,ii::!nnni1:iid 0 Retrewliar mantler <br /> 0 Used Tire Dealer @ 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§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 <br /> M <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle EnforcementLu <br /> Lu <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 In Compliance-No Violations <br /> 0 0 <br /> Other:§ <br /> 1 1 1 <br /> Comments -�D <br /> f�bLlrTln e AR4z' Aj cv) <br /> 43f,-, <br /> Inspection Form Included: 0 _f4'07/Z' Ll <br /> Comments Included: Bu ep's Signature Phone Number Inspe is Signature hone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK [Correct:0 incorrect: �N W EX AM L 1 2 3 <br /> Cop <br /> ■ <br /> White Copy:CalRecycle Yellow Copy:Operator VPink © ■ <br />