Laserfiche WebLink
Waste Tire S jey & Inspection Repor Inspection Report Number <br /> CalRecycle State of California 11 -1176551 <br /> CalRecycle 181(Rev. y(Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> TPID- <br /> usiness Profile Inspection Details <br /> , J 2 2 ? _ Inspection Type(Fill one) <br /> Site Suffix: 3 / 7 67 O / ® Routine Q Re-inspection Q Referral Q Observation <br /> Local /7 If Referral,choose referral type(Fill one) <br /> Identifier: m '�s yu Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility NamG/ Inspected By Inspector <br /> Physical Address 1 Q <br /> ,Qb��i> Fdu <br /> -2313 Xav5 D,- <br /> Inspection Date j ` / O <br /> Time In Time Out <br /> Business Rep Title 0 AM ` 0 AM <br /> -----� / A • O S ® PM ` -2 S O PM <br /> ro �.f�-r - <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 ® Generator ® Outdoor <br /> O Q Closed Q Altered <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 i <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 EXTJ N <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 /> Q Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities m <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 <br /> 1 fi yt lift 4M cpcz 46e� 4-A 4C c&C?fV— 4al 7 4_ ri <br /> Inspection Form Included: Q <br /> �`� C z ,.)vb8—aroz 3 <br /> Comments Included: ® — -- - <br /> Business p' gnature Phone Number Inspector's Signature Phone Number <br /> 00,INSTRUCTIONS ON BAC Cor`rec#. Incorrsect: E X A E 1 2 3 62os1 <br /> 'W. <br /> White Copy:CalRecycle Yellow Copy:Operator Pink opy: <br />