Laserfiche WebLink
Waste Tire irvey & Inspection Rep Inspection Report Number ■ <br /> State of California <br /> CalRecycle 11 - 1244906 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <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- Inspection Type(Fill one) <br /> Site Suffix: l _ C9 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local C t If Referral,choose referral type(Fill one) <br /> Identifier: JfI�I\7�t�l�"I r� (()IA) Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or FaacilittyfName 1 Inspected By Inspector <br /> ^ <br /> Physical Address p 1 (,'ll'S?� <br /> v0. ��� V\� l t.�i`�'L�/l9(1�n <br /> ` _ 1— � Inspection Date r7 � l O � 15 <br /> o v� 0D s CA %v4 1 <br /> Time In Time Out <br /> Business Rep Title t O AM V O AM <br /> 1 Q ® PM \J ® PM <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 /> f� Q Active Q Passenger Q Generator Q Outdoor <br /> 0 4r� <br /> GPS Latitude 0 Closed Q d/1 Q Hrqul rA AdVA <br /> 0 Q 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 Q 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 NA <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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date 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 /> 0 <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 Q Other:§ ,,' -.} l <br /> Comments 'p� r ��1Q! � 3 (�W►t. G1�1R <br /> h UA s C,��s� Ck",n a,n lA S 00 6 r cl� <br /> Inspection Form Included: Q t�pp <br /> Comments Included: Q +�Signaturel ` 8 <br /> Business Rep's Signature Phone Number Insp or, Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: E X I A M L 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop L © ■ <br />