Laserfiche WebLink
Waste Tire Sovey & Inspection Repoolnspection Report Number <br /> CalRecycle State of California I 1 - 1255819 <br /> CalRecycle 181(Rev.y(CO) 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- � ^ _ O � Inspection Type(Fill one) <br /> Site Suffix: I � `'� 1* Routine Q Re-inspection Q Referral Q Observation <br /> LocalT If Referral,choose referral type(Fill one) <br /> Identifier: SQ�y� V 4� o% - C. , Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V <br /> Inspected By Inspector <br /> Skoc\c-�tsv� \\ax�• Pc\ hv�neh� cry 0 + �` <br /> Physical Address \ 31 <br /> I _ {�/� /�^C �1 1 v <br /> Inspection Date O <br /> Time In Time Out1 <br /> Business Rep Title 1 C O AM O AM <br /> 2 ' t J 0 PM o to PM <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 /> i Active 0 Passenger 0 Generator 0 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 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 <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 EXE 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 /> Comments ;h <br /> r �C►�� t <br /> c rt C►1ce r n <br /> Inspection Formincluded:<av � (��'- <br /> Comments Included: lox I— IS U(' <br /> Business Rep's Signature Phon umber Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X7* q <br /> E X A M P L E 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LE <br />