Laserfiche WebLink
03 Waste Tire <br /> Sulve & Inspection Reportort Inspection Report Number <br /> State of California <br /> CalRecycle 181(Rev.10/10) <br /> Survey Form - Page 1 11 - 1242533 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- G S e� 6 Inspection Type(Fill one) <br /> Site Suffix: D J I* Routine Q Re-inspection Q Referral Q Observation <br /> Local ` ], If Referral,choose referral type(Fill one) <br /> Identifier: U 5(24A_ �� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ( Inspected By Inspector <br /> a C dress s v1�t7 d a r�� 3 C - 1 E S t.0'TTa <br /> Physical Address <br /> Inspection Date 1 a / ` s <br /> Time In Time Out <br /> Business Rep � Title � 'Al L4 � *AM <br /> � O PM O PM <br /> vO � , <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 40 Passenger 0 Generator ® 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 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 0 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 N <br /> Q IQ 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 <br /> Q 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement � <br /> 2 <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> Q Q Other:§ f `f <br /> Comments �1*t-V ��ftitGe_�l f� 1 n3 (}1 �i +),1`5 d A, a44 <br /> � <br /> d �;olc+r lots qJ W-(AS C- C,0'qc,e_r0 <br /> Inspection Form Included: Q M <br /> Comments Included: ®— 1\•\�N, <br /> Business Rep's Signature Phone Number nspe is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: �FEIXIA L 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop :L <br />