Laserfiche WebLink
Waste Tire Su, ,iey & Inspection Report nspection Report Number <br /> Cal Recycle State of California 11 0121019 9 <br /> Ccyclin and le 181 <br /> (Rev.Recovery <br /> Surrey Form - Page 1 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR_BLACK__I_NK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> b <br /> Site Suffix: ' 7 "� ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: Sam c��� l 0 CHP 0 CalRecycle 0 Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Coskco M A--T v <br /> Physical Address — <br /> 2-s %7- <br /> qs3?7 Inspection Date 7 / O S / ' 3 <br /> Time In Time Out <br /> Business Rep Title II \ L/ *AM 1 Q AM <br /> 1 ( PASS c k �C•c 1 0 PM r I O PM <br /> �Y� 1✓ QIVv�GL�C> e- <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 Active Q Passenger • Generator Q Outdoor <br /> O Q Closed Q Altered NI At <br /> GPS Latitude 0 Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude — O Planned OTR O End-Use O Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 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 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 � Extension <br /> O O <br /> 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 ® � 1 <br /> O Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle M6 <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> 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 O In Compliance-No Violations o <br /> O O Other:§ <br /> Comments V.,ft v�2 ���e.S� \ky-t_ w"A \OVA W^-P— C54-1 &�k ck <br /> a e <br /> Inspection Form Included: Q, L� 2 <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspe tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: 7X7*7q]jEjXjAjMjPjLjEj 12 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />