Laserfiche WebLink
Waste Tire 5Su. f✓ey & Inspection Report Inspection Report Number <br /> CalRecycle State of cle 181(R I 1 - 1177820 <br /> CalRecycle 181(Rev.y(CalRecycle) Survey <br /> 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: 3 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �- If Referral,choose referral type(Fill one) <br /> Identifier: Gan Jon iuk1 n GIA, 0 CHP ® CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 4 Inspected By Inspector <br /> 6 (3'T1-�_ CC-4cr //�� 11 <br /> Physical Address - V I CS c -D <br /> (00 k 'N \�1u�,�c,r-Sk ca <br /> -D <br /> ^id Inspection Date <br /> (D CVL �!\ <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 0 PM 0 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 /> 0 Active 0 Passen er 0 Generator 0 Outdoor <br /> o N A <br /> �� N 1/1 N 1IV <br /> Latitude 10 Closed 0 Altere <br /> � 0 Hauler 0 Indoor <br /> 0 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 0 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 I� <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 Notice Of Violation 0 Extension <br /> 0 0 <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 Ffl / M / <br /> m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX ) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years 8 <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <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 0 Other:§ <br /> Comments <br /> L)ALAt CAZA I1 <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number fn-sp or's Signature Phone brumber <br /> INSTRUCTIONS ON BA7hit. <br /> Correct: Incorrect: EXAMPLE 1112 3 62081 <br /> ® Copy:CalAe cle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />