Laserfiche WebLink
Waste Tireey & Inspection Repol. Inspection Report Number <br /> CalRecycle State cf California 11 - 1176671 ' <br /> CalRecycle 181(Rev.10/10) 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- Inspection Type(Fill one) <br /> Site Suffix: I� r 3 f 0_ 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: jpav Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business <br /> oor'Facility Name l Inspected By Inspector <br /> / rGc i b+- �►'8 G� <br /> Physical Address �l - 1 0 <br /> 130JjC n �7 ti <br /> II300 S. AY/tel Ry - <br /> Inspection Date o <br /> Time In Time Out <br /> Business Rep Title I f • 3 O AM O AM <br /> j O Q ® PM a a' ® PM <br /> �� Gc k g r, Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I® Active ® Passenger ® Generator 0 Outdoor <br /> 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 /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility ENFORCEMENT STATUS - ' <br /> I-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 EXT) 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 /> � <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 � _z 1 <br /> .,u Ytc 11?C. _cam vk� f, da <br /> Inspection Form Included: <br /> Comments Included: <br /> - -- <br /> Business Rep' Si ture Phone Number t Spector's Signature Phone Number <br /> INSTRUCTIONS ON BACK [Correct:0 incorrect: EXAM L 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:L <br />