Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of California I 1 - 1196485 <br /> CayclinglRecycle 181(Rev. yCal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery CalRecycle) <br /> Survey <br /> A-Survey BLUE OR BLACK INK PEN <br /> iness Profile Inspection Details <br /> i"plp_ -Z Inspection Type(Fill one) <br /> Site Suffix: * Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: � ad���� CQy� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> � S Inspection Date ` 0 ` 3 <br /> S � Ilk2�" Time In Time Out <br /> Business Rep Title r O PM O�AM <br /> VFW 2� �W IC.\ � L_ © J PM <br /> CIS <br /> W 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 /> 00 Q Active Q <br /> Passenger Q Generator Q Outdo <br /> or <br /> rrrNO 10 Closed Q AIteBd [A- Albl1 <br /> GPSLatitude 0Q Inactive Q TruckQHQ <br /> or <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> " Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 1* 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 /> Q 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 /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> N <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 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, <br /> 5 c` C?�S:�2v�c� C�leS cc 4( � �i_ 9►-��c e�S�gd�t:, �'C\�c Cp�� colt 1�_ <br /> e^e (!�. �o�S�`I`L`��-S CNN \N"c <br /> k—pection Form Included: Q� <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E X A M P L E 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />