Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle I - 1230296 <br /> CalRecycle 181(Rev. (cal 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- ( 0 3 _ O Inspection Type(Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local — If Referral,choose referral type(Fill one) <br /> Identifier: t4 n %kt^ co-kk Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name v Inspected By Inspector <br /> -Tr�i�o 'T��, -1 n c.- 3 _ l <br /> Physical Address d C—S Co TT d <br /> '4 �--1 o0 Pe, r u tet;s-t, . <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep `,IP Title 0 AM h 0 AM <br /> n A�eS 044)'(e � C I 5 O PM `' 0 PM <br /> NJ ln� <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 /> 0 Active 0 Passenger • Generator • Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned 0 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 1 r I <br /> Q Service Station Q Hauler Q Agriculture Q Shredder • Other �J��l�-� 0.4— ORA 5146.5 <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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 <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 /> 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 /> f <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 0 In Compliance-No Violations o <br /> Q Q Other:§ ,- <br /> Comments W L T� fc��D (1�41i a,17,1 an(� . ], <br /> Inspection Form Included: Q <br /> Comments <br /> Business R p's Signature v Phone Number Insp or's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 In ect: EXAM 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:L A © ■ <br />