Laserfiche WebLink
Waste Tire Sl.. %y & Inspection Report spection Report Number <br /> CalRecycle State of California T <br /> CalRecycle 181(Rev. (CalRecycle) Survey <br /> Survey Form - Page 1 - 1- 176513 <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 Type(Fill one) <br /> Site Suffix: C) © b 0 1 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local ( If Referral,choose referral type(Fill one) <br /> Identifier: J �,y� y�,, CQ CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address J 3 I ,I fjYZa3 * 'J G`rIIF► <br /> M" 00©U l.,,c '& l l pa"'A. <br /> Inspection Date C <br /> `T-a uy i536 <br /> Time In Time Out <br /> Business Rep Titleff 0 AM ` 0 AM <br /> It ! ' d 0 O PM 2- ! -S 0 PM <br /> d li i /Y6GCi'v !lln��'tQ,4� <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> 0 Active Q Passenger 0 Generator ® Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler ®Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned 0 OTR O End-Use Q Container <br /> Business Type(Fill all that apply) (¢� <br /> • New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader 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 Q 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 Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / IT / Q <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 O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities u, <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q em <br /> ®in Compliance-No Violations o <br /> 0 . 0 Other:§ J <br /> Comments <br /> 171 SY. 4 4-A 40— 0!A' �e%t d!t�4� 6?,AA 414 T� <br /> 11611140,4 R bq/::�f I[fd1bzI — <br /> Inspection Form Included: Q � 00,� <br /> Comments Included: ® & 69—06 23 <br /> Business Rep's Signature Phone Number nspector's Signatur Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A P L 1 2 3 62os1 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink C ■ <br />