Laserfiche WebLink
02 Waste Tire sfty & Inspection Repoi _ Ispection Report Number <br /> CalRecycle State of California <br /> CalRecycle 181(Rev. (CalRecycle) <br /> Survey Form - Page 1 I1 -1176539 <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 f _ © ( Inspection Type(Fill one) <br /> Site Suffix: / F7 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local ^ If Referral,choose referral type(Fill one) <br /> Identifier. (jtyy� ---�gy Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Phys'c ddress <br /> i9itC)O �v. l- l I <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep 1 Title 1 I 0 AM 0 AM <br /> (.�crGmS MVISr, C`3 .►Z S 0 PM V ® PM <br /> c4C GWYlIZ4 ©7_% <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 /> ' ® Active Q Passenger 0 Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR 0 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 /> M / M <br /> / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <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 0 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 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> 0 0 Other:§ —� <br /> Comments <br /> Inc <br /> Inspection Form Included: Q QQ <br /> Comments Included: 0 -36 d t'r" r�9) g68�C562 <br /> usine ep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect XE X A M E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co y:LE <br />