Laserfiche WebLink
Waste Tire Su,vey & Inspection Report Inspection Report Number ■ <br /> cle State of California <br /> CalRecycle Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 - 1196617 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Sart A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: l Lt 8 j G ) ® Routine Q Re-inspection Q Referral Q Observation <br /> Localj_, If Referral,choose referral type(Fill one) <br /> Identifier: �l✓� 1 � 6RN� t �I Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name I 1 \ Inspected By Inspector <br /> G c tC ll , 14Y r- I <br /> � <br /> Physical Ad rss ,,-� LILA <br /> �j Inspection Date <br /> � `�c) Time In 6 Time Out J <br /> Business Rep Title /L�'l�i,��I ^7 O AM O AM <br /> l vl'4WLrk5- (li[�� Ja :v,-ZG ` irlJ_ ® PM L� — I `� C� ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ' �� rf (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> o� <br /> 16 Active Q P"a�sssengger 40 Generator Q'Outdoor <br /> D Q Closed Q Alty _er �� <br /> GPS Latitude Q Hauler Indoor <br /> O 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 Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> i <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other �v � 5 1YfVt?� <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 <br /> 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 /> QQ 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date� / 1 1 MIL, <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle l <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> ® Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <br /> W <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <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:§ <br /> Comments <br /> Inspection Form Included: Q 9� <br /> Comments Included: <br /> oll _v�� I =' <br /> Bu ' s Rep's Signature Phone Number ,!Ysp tor's gn re Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: IV E A P E I 1 1 (2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co : EA ■ <br />