Laserfiche WebLink
1 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of California 11 - 2 2 303 3-4 <br /> CalRecycle 181(Rev. (Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> PartA-Sury BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ` 1 T Inspection Type(Fill one) <br /> Site Suffix: ` a l l a S lJ S Routine Q Re-inspection Q Referral Q Observation <br /> Local v If Referral,choose referral type(Fill one) <br /> Identifier: SACS �CJ U,j Cp�,t n Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address 1A%1A+J1 1kZ1 Co 2r 2 Cj CJ ! C_� cov <br /> 515 I Pe,c ;,�,'C_ <br /> Inspection Date <br /> v l <br /> Time In Time Out <br /> Business Rep Tie 5 �\ O AM O AM <br /> v+�Uttl��i unCt(t+ f 3 ; V V 0 PM 3 3 D ® PM <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 /> X *Active Q Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered IN 171s <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <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 Q Hauler Q Agriculture Q Shredder 0 Other a'-'rvvwnl CA 16"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 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-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 EXE N <br /> a <br /> Q 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 w <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> 0101 Other:§ <br /> Comments 311Q. LA)t AL1.r, ).r)S G_.41'u- ( 07:'_ IS �- GlInl/l <br /> Ny \Jib &a On1S 6( CAlcut,% [ CCfn <br /> Inspection Form Included: Q - )r)1 <br /> Comments Included: ® <br /> Hess R Signature Phone Number Inspec 's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: NA K E X A 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co : A <br />