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Waste Tire Survey & Inspection Repon - Inspection Report Number <br />State of California <br />CalRecycle 11 - 1196400 <br />CalRecycle 181 (Rev. (Cal Survey Form - Page 1 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />Dart A - Ciirvnv BLUE OR BLACK INK PEN <br />Business Profile <br />Inspection Details <br />A <br />TPID -3 _ <br />Site Suffix: <br />Inspection Type (Fill one) <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q Routine ®Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />Local �• / <br />Identifier: SC" n J G i � <br />0(,L N � c�u� <br />1 <br />Q CHP Q CalRecycle Q Complaint <br />Q Educational Visit Q Other <br />Business or Facility Name <br />rr <br />C\ C <br />Inspected By Inspector <br />Q <br />Physical AddressESC0`ri0 <br />Q <br />Q <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />Q <br />Q <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />Q <br />S's OC'�Yj.,fi (� � f A gS-ZO � <br />1 !� <br />Inspection Date ` 1 / <br />� Q,/ 13 <br />Q <br />Time In <br />Time Out <br />Business Rep Title <br />O e AM <br />A AM <br />� � � � <br />� <br />O PM <br />QPM <br />6 �LACier <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Tire Count (Whole/PTE) 3 <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />® Active <br />0 Closed <br />® Passenger <br />Q Altered <br />® Generator <br />Q Hauler <br />® Outdoor <br />Indoor <br />GPS Latitude <br />O <br />Q Inactive <br />Q Truck <br />Longitude — <br />Q Planned <br />Q OTR <br />Q End -Use <br />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 Q Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />Q <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q <br />Q <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />Q <br />Q <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />Q <br />Q <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q <br />Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />Q <br />Q <br />Other: § <br />11 <br />Comments (�Sc.V"'MS 3,fjS' /AQ'eS1rN. Cr-, ti)lIto Ilb - 90_-1n'snQ <br />k k"1 G a, <br />�f- <br />Inspection Form Included: <br />Comments Included: <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EXT) <br />Q Referred / CalRecycle Enforcement <br />® In Compliance - No Violations <br />lc <br />C r� I� 07 C bf)(st.t,/, mk.A)4!?=n (licc�o�• <br />z <br />Phone Number Insctor': <br />317 � <br />Phone Number <br />INSTRUCTIONS ON BACK Correct: i. Incorrect: EXAM . L E 2 3 62081 <br />■ White Copy: CalRecycle Yellow Copy: Operator Pink Copy: L © 0 <br />