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Waste Tire Avey & Inspection Repor Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1245117 <br /> CalRecycle 181(Rev.y(Cal Survey Form - Page 1 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I � a � q-, � � � Q i Inspection Type(Fill one) <br /> Site Suffix; r / / . Routine QRe-inspection Referral Observation <br /> LocalJ f If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name d By Inspector <br /> Inspected <br /> GLs'Pill"�;� C) o <br /> - 1 ( � <br /> Physical Address Vi/L.r <br /> t.� w0.y <br /> cf -I�20 S Inspection Date 1 0 G 5 ( S <br /> IY'I- / Time In / Time Out <br /> Business Rep Title O AM `� /(� AM <br /> �L-„ .ULC. / ka�- -f-j_ f ti.-.. I ' -3 3 e PM L� ' OWPM <br /> J��" I f lf� T(. /i�+r Operational Status Tire Type Business Role Storage Type <br /> Tire Count olj (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> e TE) It <br /> i Active Q Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR 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 <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 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 Q 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 /> Q IQ 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <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 /> lJi O�GLw oY u.�-� LP�C�.✓ \ <br /> Inspection Form Included: QJ <br /> Comments Included: • <br /> Bu I ss ep's igna ure 'Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: NJ EXAMPLE111211_3]l62081 <br /> 0 White alRecycle Yellow Copy:Operator Pink Copy:LEA <br />