Laserfiche WebLink
Waste Tire Avey <br /> & Inspection Re <br /> or , Inspection Report Number <br /> State of California <br /> CalRecycle 181(Rev.10/10) <br /> Survey Form - Page 1 1 - 1242548 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � C �^ � � � � _ O � Inspection Type(Fill one) <br /> Site Suffix: J l J I& Routine Q Re-inspection Q Referral Q Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier: SC,�n J(�(,t L1IA•'� �1J6{1 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name {Y Inspected By Inspector <br /> Physical <br /> A�ddgress 1 O �5 <br /> Inspection Date I / ' <br /> Syu cVL-�b.n G� 85105 <br /> Time In Time Out <br /> Business Rep Title 0 0 AM S *AM <br /> 1 �J ' 3 0 0 PM S 0 PM <br /> ­ <br /> S S1C.\ Owner <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 J1 Generator 46 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive a Truck <br /> Longitude - Q Planned Q OTR Q End-Use 41 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 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 <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) <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 /> uj <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 <br /> in Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments 11 Y1 <br /> � �� �(1V Q� ' (v 1 f1Sp 1 Ori x OI1 1 S If/�ft Q CAo & l <br /> No v;o 44lb?C6 y, r (f( Ann LE� <br /> Inspection Form Included: Q _ //-sSI a ���_��h D <br /> Comments Included: ® (�/ _/o <br /> dsinesispI Signature Phone Number Ins toy's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X ® q EXAM L 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co E <br />