Laserfiche WebLink
■ Waste Tire *ey & Inspection Repor Inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1226274 <br /> CalRecycle 181(Rev.10/10 <br /> (Ca)[ 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 Type(Fill one) <br /> // <br /> Site Suffix: Q la - 0 <br /> ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Nam Inspected By Inspector <br /> _�- <br /> Physical Ad ess - <br /> 77 srev <br /> lOQ - <br /> Inspection Date <br /> ./ Time In Time Out <br /> Business Rep Title Q AM O AM <br /> f2Gnr y O ®PM © 30 ® PM <br /> --- <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 /> 0 Active <br /> Q Passenger g ® Generator Q Outdoor <br /> DQ Closed d Q Altered <br /> Cies — — Q Hauler - Indoor - <br /> O p Inactive ® Truck <br /> Longitude - <br /> • Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) / <br /> Q New Tire Dealer Q Auto Repair ® 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 /> 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 d <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> W <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators in Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> �vr <br /> Inspection Form Included: O <br /> Comments Included: .,, <br /> Business Rep's Signature Phone Number Inspector.'s.Signature Phone Number <br /> INSTRUCTIONS ON BACK (Correct: Incorrect: ( EXAMPLE 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />