Laserfiche WebLink
02 Waste Tire Su, ✓ey & Inspection Report Inspection Report Number <br /> CalRecycle State of California _ — <br /> CalRecycle 181(Rev.10/10) Survey Form Page 1 11 1177759 <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: J '3 Z © I* Routine Q Re-inspection Q Referral Q Observation <br /> LocalC - �+� l If Referral,choose referral type(Fill one) <br /> Identifier: cwt V\ �C�c�v�� -EJi�'lr�J Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name U // Inspected By Inspector <br /> 00lz'�) - F) Irl, epi T c <br /> Physical Address 3 1 - f d r AAA 0/?W-i1 <br /> . �J �1 <br /> � <br /> Inspection Date \� / 7 <br /> / , <br /> Time In Time Out <br /> Business Rep Title / O AM O AM <br /> • QPM O� 41,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 /> ® Active Q Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q inactive 4&Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer 0 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 ��� � jryyZ� <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 Q - ®Notice Of Violation Q Extension <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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle v <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or Exr) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance-No Violations o <br /> 1010 Other:§ <br /> Comments <br /> r<� <br /> Inspection Form Included: Q <br /> Comments Included: ® �/ •p <br /> Buat <br /> Bus Rep's Signature Phone Number I p to s gnature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: � � � E X A P E 1 2 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Co y: ® ■ <br />