Laserfiche WebLink
Waste Tire SL„ dey & Inspection Report inspection Report Number ■ <br /> CalRecycle State of California I 1 - 1210501 <br /> CalRecycle 181(Rev. (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- ? Inspection Type(Fill one) <br /> 11 J <br /> Site Suffix: 5 1 1 O I ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> �OV�1 IAl f\ C(7U1.An Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Identifier: S(x� <br /> Business or Facility Name 1 <br /> D l I Inspected By Inspector <br /> 1 L <br /> Physical Address 3 0 <br /> C-5 co TT 0 <br /> U35S 9i <br /> Sol CA q SID J C Inspection Date 110 <br /> CJ�jI-tom Time In Time Out <br /> Business Rep Title O AM ' O AM <br /> LA 5 � � <br /> S\V1 f\ IZ4 �� ow aL m f• ® PM 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 /> I. ® Active Q Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude — Q Planned ® 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 l <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other `p-110 Mplrx�"Jl- <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 a <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 /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities u, <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 J4 e, 4-13-x( 4(211o"n, <br /> No v l u 1 A�,Io-,S Of a 4 C n c.etr). <br /> Inspection Form Included: Q <br /> Comments Included: <br /> Bu ' ess Rep's Signature Phone Number Insp or's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: EXAM L E 1 213 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy.L <br />