Laserfiche WebLink
Waste Tire Su. vey & inspec on Rep®pInspection Report Number <br /> State of CaliforniaCalRecycle CalRecycle 181(Rev.10/10) 11 -- <br /> Dept.of Resources Recycling and Recovery(CalRecycle) S`y0° `'ey Form Page 1 1 2 2 4 r� <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � A © � Inspection Type(Fill one) <br /> Site Suffix: "� 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SC4n W (t1 1, n Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name { Inspected By Inspector <br /> uN <br /> Physical Address <br /> C A 15366InspectionDate <br /> Time In Time Out <br /> Business Rep Title S S. O AM O AM <br /> ® PM A PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 1 Tom/ (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' 1 I 0 Active Q Passenger ® Generator Q Outdoor <br /> O <br /> GPS Latitude Q Closed Q Altered <br /> Q Hauler 0 Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned I* OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) o <br /> AM— <br /> Q 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 ® Other <br /> Pati 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 <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 /> 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 N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <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 /> 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 <br /> in Compliance No Violations o <br /> Q Q Other:§ <br /> Comments ( i NA cv_, t, 11 lLv-, (JA - <br /> No <br /> Inspection Form Included: Q ✓ rL171 -- 1� naubg`3171 <br /> Comments Included: ® L ` .G �y <br /> usiness Rep's Signatu Phone Number Insp tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: � � � E X A P L 1 2 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Co :L ® ■ <br />