Laserfiche WebLink
0a Waste Tire Su, vey & Inspection Report inspection Report Number <br /> State of California <br /> CalRecycle CalRecycle 181(Rev.10/10) 11 - 1230359 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 BLUE OR BLACK INK PEN <br /> Part A-Survey - <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: 105 OL 1 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ('O�^ "�'�Ct"'fv\. If Referral,choose referral type(Fill one) Educational Visit 0 Other <br /> Identifier: 0 CHP 0 CalRecycle 0 Complaint 0 <br /> Business or Facility Name Inspected By Inspector <br /> C <br /> Physical)ddress <br /> Inspection Date <br /> K� Time In Time Out <br /> Business Rep Title AM jil AM <br /> / o : � 0 0 Pm t OPM <br /> 6031/1 y Mt Cf Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) 0 Outdoor <br /> a- C' 0 Active 0 Passenger j) Generator <br /> GPS Latitude 0 0 Closed 0 Altered 0 Hauler 0 indoor <br /> 0 0 inactive ® Truck 0 End-Use ® Container <br /> Longitude 0 Planned 0 OTR <br /> Business Type(Fill all that apply) <br /> (lb New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> IQ used Tire Dealer 0 Auto Body 0 Car Deal6r 0 Collection 0 Crumb Rubber <br /> Q Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Notice of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date Fc,5-1 / M' v <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> (Required for NOV or EXT) N0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 2 <br /> LU <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance-No Violations <br /> 10 1 0 ,Other:§ <br /> Comments <br /> Inspection Form Included: 04ZLV —).Ds 01v <br /> I ace <br /> Comments Included: a si ess Rep's Signatu Phone Number pe to s ig ature Phone Number <br /> ?V IV 62081 <br /> INSTRUCTIONS ON BACK Correct:* incorrect: zs� W EX A L 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink C : 0 <br />