Laserfiche WebLink
Waste Tire SlIvey & Inspection Repor ,, 'Inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1242307 <br /> CalRecycle lel8t(Rev.y(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 C l _ Inspection Type(Fill one) <br /> Site Suffix: t lD J 0 Routine Q Re-inspection Q Referral Q Observation <br /> LocalG , f uu�l_ _ If Referral,choose referral type(Fill one) <br /> Identifier: SAf�n�j\ Lltit� ` 1\N] Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By ' Inspector <br /> Physical 31 - 1 v 1 l�C0]C0170 <br /> 3.0s5 6. Pt<-,acrso^ S4- <br /> ��"�,., <br /> �Uv+(�UI-, CA gsaDs Inspection Date `7 � O <br /> 111 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> Z. . S U 0 PM ® PM <br /> 'jW-A Ccs ski liune- 188 f 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 /> 0 Active 0 Passenger ® Generator Q Oiltdoor <br /> Latitude D Q Closed Q Altered )V,A <br /> GPS 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) <br /> Q New Tire Dealer Q Auto Repair 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 O Other ���iiu;r(,n�fat Ixj'S <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 / 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 EXTJ 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 ®In Compliance-No Violations o <br /> Q Q Other:§ 1' L <br /> Comments Ic �5O2 ' 1 �CY�' �i'm i 4b0_1 <br /> 1 <br /> NO V16LViwI3 0) wrC44s ,l� c,w, CCun - <br /> Inspection Form Included: Q <br /> Comments Included: <br /> sine ep's Signature Phone Number Insp tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X AMI P L E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:L A <br />