Laserfiche WebLink
Waste Tire SL- ,tey & Inspection Repon Inspection Report Number ■ <br /> State of California <br /> CalRecycle 11 - 1229958 <br /> CalRecycle co"er (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 /> Site Suffix: '* Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �On�] Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address M ATT <br /> �� ���� Inspection Date Q � / I ! <br /> / I <br /> Time In Time Out 1 6 <br /> Business Rep ACCO AM AM <br /> �t( <br /> 1\ 'e,2 C&0 l PM 1 I PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill ql`tt�ha�t apply) (Fill all that apply) (Fill all that apply) <br /> � � . <br /> r(� M 0 Active � ssenger Generator Q Outdoor <br /> O Q Closed Q Altered � //k <br /> GPS Latittade Q Hauler Q Indoor <br /> O Q Inactive 0 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 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 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 O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance-No Violations o <br /> Q Q 1 Other:§ <br /> Comments &Pve Oy\ AV-,-s A,d <br /> v(\0�\ <br /> Inspection Form Included: C3Z1 /36©70 <br /> Comments Included: ® O — I&A <br /> Business Rep's Si aturen Number Inspect is Signature Phone Number <br /> �( 62081 <br /> INSTRUCTIONS ON BACK Fc-orrect: Incorrect: X & �J EXAMPLE 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />