Laserfiche WebLink
02 Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Cal Rec cle state of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 - 11 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: t 40 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SWN J�6�1I L',7 fl CU t t 1/� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name J Inspected By Inspector <br /> Sa._, J0&_�L&�/_'� <br /> Physical Address <br /> S 1 CD 1 Q ac.'�i L -. - - <br /> S� <br /> A �5�� Inspection Datec <br /> Time In Time Out <br /> Business Rep Title (D1 5 S 49 AM I to 18 AM <br /> \\ 1 QPM I 1 d+ QPM <br /> Now <br /> ---— --- - - Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> • Active ® Passenger • Generator Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR End Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 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 11 <br /> 0 Service Station Q Hauler 0 Agriculture 0 Shredder Other lai <br /> l0 I c„ <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 0 Extension <br /> 0 0 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date 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 o <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 W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments , .1 tk4ti },i f e. 1 Sl'� 10 �01�2, T�\ ph Nota 4v- <br /> 0 v- <br /> No Muc s 0cf)Ac lrn <br /> Inspection Form Included: Q ��-- <br /> Comments Included: Asiness s USignattu;re PhonNumber <br /> �-,{ 62081 <br /> INSTRUCTIONS ON BACK [Correct-* Incorrect: X i E X A M P41EI 1112J3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop .L ■ <br />