Laserfiche WebLink
Waste Tire Su, vey & Inspection Report Inspection Report Number ■ <br /> Recycle State of California <br /> Cal Rec <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 - 1176401 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> part A- Survey _ BLU E_OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ` +r/ C' - I Inspection Type(Fill one) <br /> Site Suffix: l l D (0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �R �ULt�1/�l f� COIAX4L� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name L Inspected By Inspector <br /> V4 _j���� Cc q - r b 1 <br /> Physical Addresqj J Re, EA,( 3A `Ao�vntn <br /> Inspection Date �j 2 1 ut I <br /> Time In Time Out <br /> Business Rep Title I j 0 AM Q 0 AM <br /> PM � 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) V (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active • Passenger • Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O Q Inactive 40 Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber n <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other T1 al. ANzy4ion ( go41� <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> ®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.'I / TS MIJ <br /> O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE n <br /> a <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 /> 2 <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities u, <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance-No Violations o <br /> Q Q Other:QQ§ <br /> Comments o t- ��cf lsk� 1'11 fog i(1� ��t 11� S T(,I.{1Q��- [9 i1 I YI J �� GA <br /> o4c' 1 <br /> Inspection Form Included: 01 <br /> Comments Included. <br /> — "` Lns <br /> *er'. -usiness Rep's Signa ure Phone Number ISignature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON CK Correct:0Incorrect: 1, E X A L� 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink C py: ■ <br />