Laserfiche WebLink
03 Waste Tire SL%ey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle — ■ <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1242289 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I n - y� 1 Inspection Type(Fill one) <br /> Site Suffix: Yj o ) e Routine Q Re-inspection Q Referral Q Observation <br /> Local �- If Referral,choose referral type(Fill one) <br /> Identifier: S �� J O(A-1 L11 / �yvtnt Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 Inspected By Inspector <br /> 6fA� r)3 A B 2;,G d 3 a - <br /> Physical Address <br /> Inspection Date 0, / 1 a / 1 U <br /> Time In Time Out <br /> Business Rep Title ®AM l 0 _` ® AM <br /> �`- Q PM l U O PM <br /> V 0 Sle. 2gmi rCs� �1.AjX)fP <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (r J h (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> • Active 0 Passenger ® Generator 0 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 Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer ® 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date 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 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 <br /> 11 <br /> 1 a if on 5. o Ln D C.Gf n <br /> Inspection Form Included: Q , <br /> Comments Included: ® ZO� ✓ v"1`� <br /> Busines Re 's Signature Phone Number Insp or's Signjure Phone Number <br /> INSTRUCTIONS ON BACK; Correct:0 Incorrect: EXAM E I 111213] 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co.y. © 0 <br />