Laserfiche WebLink
0 Waste Tire S-.vey & Inspection Repoi _ Opection Report Number ■ <br /> CalRecycle State of California 11 -1176459 <br /> R <br /> CalRecycle (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- � � 2 © � � ' 1 y _ � � Inspection Type(Fill one) <br /> Site Suffix: J Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one <br /> Identifier: SG),(1 J Q LLJ LAI,n CGw)� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Com -1()C_ 3 S I o 1 n n �o <br /> Physicallll...JJJJ����lAddress J n - � ES <br /> Inspection Date � � a S � 1 <br /> I� <br /> Time In Time Out <br /> Business Rep Title (� (� O AM 0 AM <br /> v v 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 /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 19 Closed 0 Altered I� 1�(A <br /> GPS Latitude ��! 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> V <br /> Longitude - 0 Planned 0 OTR 0 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 <br /> 0 Service Station 0 Hauler 41 Agriculture 0 Shredder 0 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 /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) 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 /> 2 <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 <br /> \v" M(1u <br /> I <br /> Inspection Form Included: 0: <br /> Comments Included: 0i <br /> Business Rep's Signature Phone Number Inspect r Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: c G✓ E X A M P L E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />