Laserfiche WebLink
03 Waste Tire Su. ✓ey & Inspection Report Inspection Report Number ■ <br /> CalRecycle s=ate of California 11 - 1230420 <br /> CalRecycle 1 R(Rev.Recovery <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- 7 1 Inspection Type(Fill one) <br /> �! �7 C� 0 <br /> Site Suffix: ` - 5 1 ` , Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: v L Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 'Y Inspected By Inspector <br /> _ 1 Q 1 A A n � <br /> Physical Address Tv <br /> J 1 1 /vl/-� <br /> -791 <br /> n Inspection Datec) 9 / Z G <br /> C _I 5206 Inspection <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 30 0 P © QPM <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 /> ' Q Active QPasspgger Q Generator Q Outd or <br /> O 0 Closed Q ARered Y'1_ <br /> GPS Latitude Q Hauler nl <br /> O 0-Inactive Q 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 0 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 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 <br /> 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 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) 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 1 Q 1 Other:§ <br /> Comments <br /> �o �i.c� i` c>Ira Ls'__ c Gc eco <br /> I` •�� %45: ea, l xc,sMc>.9 6„ 2431 �� I��; �1-2 9 Zl 1 S —off ct�ln <br /> .�►�� a � 6�s a� 72A [bs - AA,-,s'TmL`�. <br /> Inspection Form Included: Q ob — ^3 <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspect is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: �XIEIXIAIMIPILIEI 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />