Laserfiche WebLink
Waste Tire Sup vey & Inspection Report Inspection Report NumberStte of ■ <br /> CalRecycle CalRecycleli1881 or(Rev.10/10) I1 - 1196259 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- C] 1 Inspection Type(Fill one) <br /> Site Suffix: 1 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local ((""-� If Referral,choose referral type(Fill one) <br /> Identifier: Sa-r -Soo_otv\n 19vv�-' Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name f <br /> Inspected By Inspector <br /> Physical Address 3 l - ' C ` �v l A-T V <br /> 3$d2 VJAto)c <br /> ^ Inspection Date C) ` / 4 <br /> S oc�c�ov� C J 1S2�5 <br /> Time In Time Out <br /> Business Rep Title d 0 AM 0 AM <br /> -L � PM � �PM <br /> Cra c�oS Y\a_ ®wV\e(- <br /> 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 /> 0 Active a Passenger ! Generator * Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q 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 /> Q New Tire Dealer ! 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 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 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 orEX7) 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 /> 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 ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> z <br /> Comments � <br /> '�o��'•v�2 N�r p__ Nva N e.G�r;c'V\ A MNR lzNN .S fG1�► c \r <br /> ��o_�1'_Q��- •ov. r <br /> Inspection FormIncluded: Q <br /> Comments Included: -- <br /> Busin ss a 's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: EXAMPLE 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />