Laserfiche WebLink
Waste Tire Su. vey & Inspection Report _.spection Report Number ■ <br /> CalRecycle State of California I 1 - 1226514 <br /> CalRecycle 161(Rev.10/10) Survey Form - Page 1 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Survey <br /> Survey BLUE OR BLACK INK PEN <br /> Part A <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> C)Site Suffix: l !37 S 0 / ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address �� S{ G .3 - O <br /> g�feT/jg:N <br /> Inspection Date <br /> liqs 3F'L Time In Time Out <br /> AM O AM <br /> Title ® <br /> Business Rep / / , 3 Q O PM 0 A PM <br /> S �;o r C_ r cry 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 ® 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 ® Container <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair 40 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 /> VI A I 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 /> 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 EXT) N <br /> r <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 /> LU <br /> LU <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations <br /> Q Q Other:§ 1 <br /> Comments �� <br /> l�n���)24_ CAC4ey 7�77i <br /> e UJ <br /> Inspection Form Included: Q <br /> Comments Included: <br /> ®fit/� k44mnlcfL, <br /> Business Rep's Signature Phone Numbern�ctor's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: N (� E X A M 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co y. © ■ <br />