Laserfiche WebLink
Waste Tire Survey & Inspection Re of Inspection Report Number <br /> CalRecycle State of California <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 11 - 1244911 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- S q p� r Inspection Type(Fill one) <br /> Site Suffix: I 1 ` b l 0 Routine Q Re-inspection Q Referral Q Observation <br /> LocalC // If Referral,choose referral type(Fill one) <br /> Identifier: SQ>7 (pj u,,, l{j ur, O CHP 0 CalRecycle 0 Complaint O Educational Visit O Other <br /> Business or Facility Name Inspected By Inspector <br /> NO- W4k(�L �(OL�_p `� <br /> Physical Address 1 J <br /> Inspection Date '/ <br /> Time In Time Out <br /> Business Rep Title O AM [f O AM <br /> 3 ii 1 0 ® PM —L PM <br /> u1 S J 1(+(lc n E� �1 u nT m �- <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 0 Passenger ® Generator 0 0 tdJoor <br /> O 0 Closed 0 Altered - "J <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O Q Inactive ® Truck <br /> Longitude — O Planned OTR O 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 O Hauler 0 Agriculture 0 Shredder ® Other I ckP#P "U jIA PaU[+'Jt <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 0 Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle 4 <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> O Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> Q 0 1 Other:§ ]1 l I <br /> Comments C34 <br /> �_MS in wW <br /> N c b r- a( 4 conc e-rrt <br /> Inspection Form Included: 0 2oJ)IL`��+3 <br /> Comments Included: _ <br /> dines ep's Signa Phone Numb Inspe t is Signature Phone Number <br /> dines ep' <br /> INSTRUCTIONS ON BACK Correct: III62081 Incorrect: E X A M P E 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:L A <br />