Laserfiche WebLink
Waste Tire E&y & Inspection RepoNpection Report Number <br /> CalRecycle State of California *ti - 117 6 6 4 3 <br /> CalRecycle 181(Rev.y 0) 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- ` S 3 f - 1 Inspection Type(Fill one) <br /> Site Suffix: I `i Routine ® Re-inspection 0 Referral Q Observation <br /> LocalC� 1 If Referral,choose referral type(Fill one) <br /> Identifier: qvh ^'r�CtiCh,u Vw O CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> ca A i rC_ y-,j �� <br /> Physical Address <br /> 4 �� C . F(rl✓Y)GYI c�r <br /> Inspection Date 0 / Z,• ' <br /> Time In Time Out <br /> Business Rep Title ® AM ® AM <br /> C f © d O PM ( 3 Q 0 PM <br /> Into, Ltxyc,6 '1tt10 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 Passenger ® Generator ® Outdoor <br /> Latitude O O Closed Q Altered ®- <br /> GPS - -- - n Hauler 4ndaor- <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR 0 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 /> • 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 /> Notice Of Violation Q Extension <br /> O 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / FR / m <br /> O Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) <br /> O 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> O Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Other:§ <br /> Comments f- <br /> ��_ fYiG(�•P�1(ati+ �i S �lllf-1 __ 'M4t ��U�7 V19� .,, <br /> 1" V-0 it-CA :1 <br /> Inspection Form Included: Q <br /> Comments Included: is - <br /> Business Raws Sig a Number Iftifector>4kignature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect E X A P 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pinkpy: <br />