Laserfiche WebLink
® Waste Tire S ley & Inspection Repor Inspection Report Number <br /> CalRecycle State of California 11 -1176565 <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- Inspection/ 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: i IrYI <<JuA w CCVA-k�c.t Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Nam U J Inspected By Inspector <br /> Oaq c' --V 6q V-- <br /> Physical AddresJ <br /> � <br /> �✓1 GS z <br /> Inspection Date l s lJ T <br /> C�t 7 Time In Time Out <br /> Business Rep Title ® AM S AM <br /> f D S Q PM / /? S Q PM <br /> 1�c�#-au�v cvn• �;c,�• j2rtn�c <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 /> ® Active Q Passenger ® Generator Q Outdoor <br /> GPS Latitude 0 Closed Q Altered <br /> Q Hauler Q Indoor <br /> 0 Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) IV <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 ® Other <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 O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / M / <br /> 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 <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 <br /> Q Q Other:§ - <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: 0— <br /> ���'«�' C2�t <br /> Business Re Signature one Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK [Correct:-Incorrect X *_� E X A M P 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy: EA <br />