Laserfiche WebLink
Waste Tire &L Bey & Inspection Repor, Inspection Report Number <br /> CalRecycle State of cle 181(R I 1 - 1210327 <br /> CalRecycle 181(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- Inel zspection Inspection Type(Fill one) <br /> Site Suffix: k 13 4 Q Routine ® Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 56'�� 1'6 V\V., CoQ CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name • , Inspected By Inspector <br /> ` c��c C��� �c n�o, - O 1 )kA A T T 'V <br /> Physical Address <br /> Inspection Date � / , � / 3 <br /> cA ct S 2c6 <br /> Time In Time Out <br /> Business Rep Title c *AM O AM <br /> !L J 0 PM Z Q e 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 /> ' 1 0 Active Q Passenger ®Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude 9 Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned ® OTR Q End-Use 41 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 •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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date 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 EXT) N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 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 Q1 Other:§ <br /> Comments \�5� CSlr\ mzs _&O ocy C'k <br /> �ce,�:r�•3S V;e�,a.�:n�n �n,r,-S �•e c..r __ �c c�-c�c� <br /> wn 2 <br /> Inspection Form Included: Q <br /> Comments Included: • <br /> Business Mp's Signature Phone Number Inspec or's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: M �jEjXjAjMjPjLjEj 1112 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />