Laserfiche WebLink
T 02 Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> i, <br /> CaI Rec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 11 - 1226679 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey __ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- (b _ I Inspection Type(Fill one) <br /> Site Suffix: ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Sa /��vu�J ��� CQt,I fl� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or acility Name` 1 I1 Inspected By Inspector <br /> (_Lk$A)ctl /`� <br /> Physical Address C 3 I V <br /> mo ` � . q w �• ]_(_0 II <br /> In �-� <br /> Inspection Date l / U / <br /> L; �� q�310 ' <br /> Time In Time Out <br /> Business Rep Title I 0 ® AM (� C� O AM <br /> 3 �/ 0 PM ® PM <br /> - <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) / 5 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active ® Passenger Generator ® Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive ® Truck <br /> Longitude - 0 Planned ® OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 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 0 Hauler Is Agriculture 0 Shredder 0 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 /> 0 O 0 Notice Of Violation 0 Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) <br /> r <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments h.1 1\_ n I �� <br /> _! <br /> cm <br /> 3 r, I eu co cer , <br /> X10 �j Ct�1 S B i u � (� rl n <br /> Inspection Form Included: 0 C4 46 0 Rw4wfrj�\ — <br /> Comments Included: <br /> Business Rep's Signature Phone Nbmber Insp or's Signature Phone Number <br /> �-,�( 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: � w NJ E X A M P L 1 2 3 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink C y: © ■ <br />