Laserfiche WebLink
Waste Tire 9%ey & Inspection Reporwspection Report Number <br /> Cal Recycle State of California <br /> CalRecycle 181(Rev. 11 -11766u7 <br /> (Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle( <br /> Part A-Survey BLUE OR BLACK INK K_PEN <br /> Business Profile Inspection Details <br /> TPID- i 2 _ Inspection Type(Fill one) <br /> Site Suffix: U ® Routine Q Re-inspection Q Referral Q Observation <br /> Localeni If Referral,choose referral type(Fill one) <br /> Identifier: soy1 " w Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 Inspected By Inspector <br /> Physical Address 0 f 0 / %I /V <br /> o,a <br /> Inspection Date <br /> CA IS-336 <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> Aq / 0 � Q ® PM ( ® PM <br /> -- - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) C' (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® 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 Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other <br /> I !Zt/Lt•'lr �i1.�s <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 /> PRC 42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q § 9 Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / M / <br /> '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 <br /> (Required for NOV or EX7 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 /> Inspection Form Included: Q <br /> Comments Included: ® �-- r --- -- �• <br /> ess R g Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:i Incorrect �� E X A M NLJEJ -1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink C:PV--r-� <br />