Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CalRecycle I 1 - 1210424 <br /> CalRecycle 181(Rev. (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- " p� Inspection Type(Fill one) <br /> Site Suffix: "l (J ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: J�- (� i r� C(�1,(rl Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name _ ` Inspected By Inspector <br /> Physical(press V <br /> USOS <br /> 1 CA <br /> ^��I Inspection Date `7 3 <br /> Time In Time Out <br /> Business Rep Title 6 AM • AM <br /> 22 _ U 0 P U 5U QPM <br /> v.� u►rY,;n ��s ci S ��Y- � S- <br /> Operational Status Tire Type Business Role Storage Type <br /> �y( <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �(J <br /> Q Active • Passenger • Generator Q Outdoor <br /> O * Closed Q Altered P./A <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive S 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 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 <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 / 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 EX77 n <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 m <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators A In Compliance-No Violations o <br /> Q Q Other:§ <br /> 1 <br /> Comments �O-.1� t.dLhfj� T � 1]_ lJ� 1�� <br /> 1k�T s�)n �[/ C� bl ��J�J <br /> WM <br /> N)O Nid� <br /> Inspection Form Included: Q <br /> ui 2c71 .. <br /> Comments Included: <br /> Business Rep's Signature Phone Number Insp tor's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect:. � V E X A P L E 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cpy- <br />