Laserfiche WebLink
0 Waste Tire SL.. vey & Inspection ReporOInspection Report Number <br /> calRec cle State of California — <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1230304 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- c1 '1 _ O 1 Inspection Type(Fill one) <br /> Site Suffix: o� a[1 ` 6 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local N If Referral,choose referral type(Fill one) <br /> Identifier: �n�QU�UI t Cuu�}� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> _F�7 7611-c ;�,c�, nom. - 0 t <br /> Physical Address V <br /> Ilk <br /> Inspection Date 1 / / 1 S <br /> wN Time In Time Out <br /> Business Rep Title C 0 AM AM <br /> Sia �u`l 1 'lead i`c1 T- � ® PM O � � 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 /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler � Indoor <br /> O 0 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 4§ 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 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 00 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date FH / M / M <br /> 0 0 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 EXE 18459.2.1 <br /> a <br /> 0 0 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 0 Referred/CalRecycle Enforcement <br /> 2 <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 0 Other:§ ,L _] .}. <br /> Comments ���v'►�^e. (�n�/L4C. T moi( _O'e� i tt7--. OL!ro (J� 1,(, n S ��1�� Uynj 1�4 <br /> - <br /> - Nu -\0'01 1' v�ns OI uj"CAs o' Contzfn <br /> Inspection Form Included: 0 3 <br /> Comments Included: � <br /> Bu ness Rep's Si ture Phone Number Ins tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: X rJ E X A M P E 112 31 <br /> 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:L <br />