Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Cal Recycle State of California I 1 - 1226591 <br /> CalRecycle 181(Rev. (Ca), <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 <br /> Part A -Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection- Inspection Type(Fill one) <br /> Site Suffix: 7 1 �J 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local ( L If Referral,choose referral type(Fill one) <br /> Identifier: se'n �Q LAI,1) C(gunT Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> JX UAV icr Lut f r,. � � - <br /> Physical Address 01 C3w�z <br /> `? • Vd Sc,�-n1*r- Ave-, <br /> CA 9� � Inspection Date <br /> Time In Time Out <br /> Business Rep Q Title e *AM / 0 AM <br /> -J 0 PM I v O O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> 1 �� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active ® Passenger @ Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude (111Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use ® Container <br /> Business Type rF' 3!1 that arr�v) <br /> New Tire Dealer O Au►r+Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Used Tire Dealer Q Aur.Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q H.3:,or 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-Reg:Z~ation/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> Q 14 CCR§18459.1 -: Program ID Number from CalRecycle <br /> Q Q 14 CCR§18459.2.' Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE h <br /> 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 u, <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments1 b <br /> C<01k�f1SL_. Vit ��c, ti fL t f15 11111 dOnk <br /> ksjj- <br /> Inspection <br /> Form Included: Qi�0,ine <br /> Comments Included: IWCG� <br /> Rep's Signature Phone Number Inspe is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X � (/) E I X I A M E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy: © ■ <br />