Laserfiche WebLink
Waste Tire Sui vey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CalRecycle — <br /> CalRecycle 181 Survey Form - Page 1 11 1196418 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: ` j O 0 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name ( Inspected By Inspector <br /> Physical Address 9L <br /> 76 0 iq <br /> ,(� Q`SL Inspection Date <br /> I GL✓� �� - Time In Time Out J <br /> Business Rep Title O AM O AM <br /> ' 3 ® PM ' j C-2 0 P <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 3 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> • Active • Passenger ® Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ® Indoor , <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer (P Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 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 <br /> 0 0 - --_ - �Notice Of Violation � Extension <br /> 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 /> 00 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / � / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXn N <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 /> LU <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> 0 1 0 1 Other:§ _ <br /> Comments c <br /> \ N <br /> Inspection Form Included: 0 <br /> si <br /> Comments Included: Wd ��ZeT <br /> ss Rep's Signature Phone Number irigpictoSi6ature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect: EX A M L E 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy L ® ■ <br />