Laserfiche WebLink
■ <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of California 0 - 1176750 <br /> CalRecycle 181(Rev.10/1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE <br /> Form - Page 1 BLUE OR BLACK INK PEN <br /> PartA -Survey <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: C) IS Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local C If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 3 0 C'-X <br /> Inspection Date C) 0- <br /> ce)a Time In Time Out <br /> Business Rep Title0 AM 'S 0 AM <br /> 2 b PM OPM <br /> N <br /> &I Ld <br /> Operational Status Tire Type Business Role Storage Type <br /> C (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> Active 0 Passenger Generator Outdoor <br /> GPS Latitude 0 Closed 0 Altered 0 Hauler indoor <br /> 0 Inactive 6 Truck <br /> Longitude 0 Planned OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer Q Auto Repair Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 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 /> — <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 N <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> (Required for NOV or EX7) 6i <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 Enforcement <br /> 2 <br /> w <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:§ <br /> Comments <br /> Inspection Form Included: 0rte, I. 4) <br /> Comments Included: 0 --- Phone Number Ins e_ r'sSi at ePhone Number <br /> Business Rep's Signature 62081 <br /> INSTRUCTIONS ON BACK Correct:* incorrect: E X A P P 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co A © ■ <br />