Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1230307 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <br /> 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- 1 1 1 Inspection Type(Fill one) <br /> Site Suffix: 40 Routine Q Re-inspection Q Referral Q Observation <br /> Local e t If Referral,choose referral type(Fill one) <br /> Identifier: JAf1 JOun co"A41, Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 11 Inspected By Inspector <br /> Corc,MQrGI(Ai ro, <br /> Physical Address <br /> \ - Inspection Date <br /> CA cis ti S <br /> Time In Time Out <br /> Business Rep Title C) c 10 AM -c ®AM <br /> �S�AI'�k �t�1� �Cd.� U.n� 1 v I J 0 PM J 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �p t <br /> • Active ® Passenger • Generator I* Outdoor <br /> Q Closed Q Altered <br /> �PS Latitude Q Hauler ® Indoor <br /> D Q Inactive 41 Truck <br /> Longitude - Q Planned lb OTR ® End-Use Q Container <br /> Business Type(Fill all that apply) w--�W <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> O 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 <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 EXE 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 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:§ <br /> Comments RpU��f� WeNS ��rc• f� A4 yn 6 Cy�'}1/1�5 �Gv��1fick <br /> Nu v 10 (A�TJNr, nr ttifesnS CAnUfn, <br /> Inspection Form Included: If <br /> ® (� <br /> Comments Included: ® , R" <br /> - <br /> ne s Rep's Signature Phone Number insp tor's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E X A I 1 2131 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co y: <br />