Laserfiche WebLink
Waste Tire Su, ✓ey & Inspection Report inspection Report Number <br /> CalRecycle State of California I 1 ® 1196556 <br /> CalRecycle (Rev.10/10) <br /> Recovery <br /> 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- � � � I Inspection Type(Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �(�� �6qp V;r C�V Q CHP Q CalRecycle Q Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 1 Inspected By Inspector <br /> - 1 b T v <br /> Physical Address <br /> 1b X77 I\ �T�}1,cc� - <br /> ��� Inspection Date C51 / (� i <br /> L � C I <br /> Time In Time Out <br /> Business Rep ITitle \ G 0 AM O AM <br /> ZV� �•t�C'�. �l.�Mh1,f�A,� `• � 1 1 J QPM PM <br /> � � ® � � <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 /> O Active 0 Passenger 9 Generator 00, <br /> Ou door <br /> ��" <br /> o Q Closed 0 Altered <br /> pS Latitude <br /> 0 Hauler 0 Indoor <br /> 0 Q Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> 0 O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <br /> a <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> LU <br /> 0 0 14 CCR 18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> § <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> 10 1 Q 1 Other:§ <br /> Comments �Ov\,�2. ,.a��✓—��'�'_ ��nSQ2L�jf�1 (�j�n� 0 Y� �\S (�,�a.�k�r�� ,� <br /> e <br /> Inspection Form Included: 0 <br /> Comments Included: <br /> u ness Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: IEIXIAIMIPILIEI 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />