Laserfiche WebLink
............. <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> calRecycle CalRecycle 181(Rev.10/10) 11 - 1196635 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey 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: 3 9 o S Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: V\, 0 CHIP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> X(X vVic, <br /> Physical Address LIL-14 <br /> 670-1 ci � 'yase�ri-1, �-c Inspection Date t / ,,?- t 1 3' <br /> vlovt�'r_c,;'_ CR 0r5'TS--7 Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> rtavlueA 0 PM QPM <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 /> (S Active 0 Passenger (& Generator 0 Outdoor <br /> GPS Latitude 0 0 Closed 0 Altered ® Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude 0 Planned 0 OTR End-use 0 container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station a 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 / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) N <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 Enforcement <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 Other:§ I <br /> Comments <br /> 0 V 7' <br /> Inspection Form Included: 0 <br /> Comments Included: (9 <br /> u iness aRepWs Signa ure Phone Number lntpeptor's,5jg ature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: EXAM <br /> I — �LJEJ 111213 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA 0 <br />