Laserfiche WebLink
Waste Tire Sw Bey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1245078 <br /> CalRecycle dRcover (Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- S_urve_y_ _ 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: `y Q CHP Q CalRecycle Q Complaint O Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> zo-\11r S G--c-ocf.cy � <br /> Physical Address M � <br /> Inspection Date O <br /> Time In Time Out <br /> Business Rep Title i�,Cy\'p C O AMO AM <br /> (� M(�-r` r 1 0 PM Z 2 O PM <br /> c2 ` C Oen F1'�-�C' S2c <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 Q Passenger 0 Generator Q Outdoor <br /> Q Closed Q Altered N <br /> lA- <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive * 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 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 m / 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 EXE n <br /> Q O 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 /> 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 Other:§ <br /> Comments g �C,, ;�� ;ns <br /> ��a --`K�� P�QS \��Or�\1C5 <br /> �,y - <br /> CICO hCe` <br /> Inspection Form Included: Q 01 <br /> Comments Included:-0Ad *44�4-f G 28q 4eB Ja / <br /> Business Rep's Sign ture Phone Number Insp tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: (� E X I A I M L E 3 62081 <br /> 2 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop L <br />