Laserfiche WebLink
Waste Tire SL..vey & Inspection Report Inspection Report Number <br /> CalRecycle State of California — ■ <br /> CalRecycle 181(Rev. (Cal Survey Form - Page 1. I1 1230391 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> )art A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- L{ C) Inspection Type(Fill one) <br /> Site Suffix: Q Routine Q Re-inspection Q Referral Q Observation <br /> Local ` _- Vk `„C. `_1 � C,0�� If Referral,choose referral type(Fill one) <br /> Identifier: �lil -X f!�"'. l Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Cet.l�v��Lc..S ►`1c�I-��,� t T�n� � � �t <br /> Physical Address Lrj ( A K`�g(vLA <br /> L`lY s L_,,- -H f <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM 2 Q AM <br /> 157 ® PM v � � ® 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 /> V ® 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 ® OtherG,�o {� � �r�t1'7 �«✓ <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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 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 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> v <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 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations <br /> Q Q Other:§ <br /> Comments <br /> �F�tYl�ttivl,C, !''ac _ N <br /> Inspection Form Included: Q <br /> Comments Included: Is <br /> Business Rep's Signature Phone Number InA ctor' Snature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E X A M,' L 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop L �� ■ <br />