Laserfiche WebLink
Waste Tire Survey & Inspection Repor ., Inspection Report Number <br /> CalRecycle State of California 11 - 1242534 <br /> CalRecycle 181(Rev.y(CalRecycle) Survey <br /> Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- `� r� 1 _ Inspection Type(Fill one) <br /> Site Suffix: [ J 1 • Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ��n V (�� i G)U1-n 111 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name J Inspected By Inspector <br /> ll�J-t-r 4S bac. 3 _ n 1 <br /> Physical Address CsC OTTO <br /> Lull � � Inspection Date <br /> Time In Time Out <br /> Business Rep Title o� O AM O AM <br /> oC U 0 PM O • PM 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 /> Is Active Q Passenger Q Generator Q Outdoor <br /> / <br /> GPS Latitude O Q Closed Q AltQreGi ® Hauler Q Ind of A <br /> O Q Inactive Q TruC <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q 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 Hauler Q Agriculture Q Shredder ® Other Q)OW+ SOLV{-mow <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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) N <br /> v <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 w <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> L' GU.ncefn_ <br /> Inspection Form Included: Q a'O q 'A/7 0�) AO)� <br /> Comments Included: <br /> 333 9500 464 1 -- <br /> Busi ess Rep's Signature Phone Number Inspe is Signature Phone Number <br /> �-�( 62081 <br /> INSTRUCTIONS O CK Correct: Incorrect: X NJ E X A M P L E 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy LFA <br />