Laserfiche WebLink
■ Waste Tire Survey & Inspection Report -Inspection Report Number ■ <br /> State of California <br /> CalRecycle 11 - 1196375 <br /> ry <br /> CalRecycle 181(Rev.y(Ca), 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� I Inspection Type(Fill one) <br /> Site Suffix: 9 Routine Q Re-inspection Q Referral Q Observation <br /> Local -- ) If Referral,choose referral type(Fill one) <br /> Identifier: S All, J o al w j-� leu( "t Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical AddressCA I �c��� <br /> 1'.A Inspection Inspection Date 1 / l 3 I L4 <br /> " �� S Time In Time Out <br /> Business Rep <br /> � I ^ � (T�itleO AM O0 AM <br /> C Q� . _ Q0 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 /> • Active Q Passenger ® Generator Q 1Ouutdoor <br /> O Q Closed Q Altered ,v A <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive A 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 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other Qilzj <br /> G�n <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 <br /> 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 <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 /> Q Q Other:§ <br /> Comments Q,UAki' �1 f 1 �+ �� ,r �Wc 4-06A <br /> N <br /> AA <br /> 0 et <br /> N o <br /> Q'10 ' s of uj pws, 0 concern- <br /> Inspection <br /> o ernInspection Form Included: Q ) Cb �/�� <br /> Comments Included- ® c�� 'o <br /> BuLess ess gnature Phone Number Inspe t is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: g E X A M P ^L E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy: EJ © ■ <br />