Laserfiche WebLink
Waste Tire Su. ✓ey & Inspection Report Inspection Report Number <br /> cle State of California <br /> CalRecycle CalRecycle 181(Rev.y(Cal Survey Form - Page 1 I1 1245030 <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: b * Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: G V\ V4\ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name cInspected By Inspector <br /> c <br /> Physical Address V <br /> �., <br /> Inspection Date D L / I r <br /> rf / <br /> ` a}�, ����0 Time In (' Time Out <br /> Business Rep Title I 1 O AM 2 10 AM <br /> QPM QPM <br /> «"� I✓+` �•`v C �' 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 /> Q Active Q Passenger Q Generator <br /> QOut o <br /> r <br /> PS Latitude O0 Closed Q AlteedL )leQ/IYX <br /> GO Q Inactive Q Truck Q�au( ndoor <br /> Longitude - Q Planned Q OTR o 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 0 Other �CSeC <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 Notice Of Violation Q Extension <br /> 0 o <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 o PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 o PRC§42956-Registration/Decal in Vehicle <br /> 0 0 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 /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance-No Violations o <br /> 0 1 o 1 Other:§ <br /> Comment��,��\ OWN. � Q &N L <br /> \o- aY•S cc �6r�Ce`r <br /> s -o <br /> - �1 <br /> Inspection Form Included: <br /> of e 604 7) 7-,�7 AD ` *./--- -`�323 Ll <br /> Comments Included: QBu iness Rep's Signature Phone Numbertor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: M � EXAMPLE11127362081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />