Laserfiche WebLink
Waste Tire Avey & Inspection Repor ,, Inspection Report Number <br /> CalRecycle State of CaliforniaI 1 - 12 5 5 9 6 0 <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- Inspection� n - � � Inspection Type(Fill one) <br /> Site Suffix: 1 L 1 06 le Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SQ r �a� V y\ �y Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Sti,���tw v�ak�o� °� - C� 'T `�v <br /> Physical Addr ss <br /> Inspection Date ` 2- <br /> Cosy C ��� 53-77 Time In Time Out <br /> Business Rep Title O AMO AM <br /> I, ' S O 0 P � � JePM <br /> �•t,,.�cev� Qc � �c� <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 Q Passenger 0 Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned • 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 4D Other ,A,{ -te3X <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 / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXTJ N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <br /> Q O 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 <br /> In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments n _ _,kyle A7%lre <br /> leo v�S 6'c AceaS o� Cov�Ce('y� <br /> Inspection Form Included: Q �yj -20g1q U 9-3n <br /> Comments Included. 1 t� l� <br /> Business Rep's Signature Phone Number Inspe tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: ® � E X A M P L E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />