Laserfiche WebLink
Waste Tire Survey do Inspection Reporn lnspt:�.._ ;on Report Number <br /> CalRecycle State of California I 1 - 1210221 <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: �� d Z CA 1 © ® Routine Q Re-inspection Q Referral Q Observation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identifier: �(.� ��-G�f���. �E��-1'L -- Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 111 Inspected By Inspector <br /> - f 1&i �— � _ A <br /> Physical Address 1 ,�-r�}-Iry(_L4L4, <br /> Inspection Date <br /> Time In Time Out 6 J <br /> Business Rep Title <br /> �vA ` <br /> T' 2i C2 ® PM 1 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) —70 <br /> -6 7 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' 0 ® Active Passenger 0 Generator Q Outdoor <br /> D Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> ® 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 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I 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 /> PRC§42956-Registration/Decal in Vehicle <br /> QQ 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 EX7) N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> uj <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 Oln Compliance-No Violations o <br /> Q Q Other:§ -- _ <br /> - - - z <br /> Comments <br /> of( P7 <br /> Inspection Form Included: Qr <br /> Comments Included: &-i-46x—76 <br /> Busines Rep's Signature Phone Number n is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E I X A 1 111213 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co y: ® ■ <br />