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Waste Tire EOvey & Inspection Repor ,, Inspection Report Number ■ <br /> CalRecycle State of California - .1230118 CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 12 3 0118 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- © 1 Inspection Type(Fill one) <br /> Site Suffix: I tJ t / �Routine a Re-inspection Q Referral Q Observation <br /> Local 3009 / 1� If Referral,choose referral type(Fill one) <br /> Identifier: Sn J 1,�1J� �,,,(7�,1f�� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> CbnUen'%QAt �,(A urL, 3 9 - 1 p l <br /> Physical Address CS60TTo <br /> V <br /> CA Inspection Date 5 O '5 l S <br /> Time In Time Out <br /> Business Rep Title ' I S �AM AM <br /> � � � ' � <br /> �SS� QPM QPML KkkA(A(- ow�c,r" <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) tl (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> o ® Active ® Passenger ® Generator Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer 0 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 Q 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 /> 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 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXTJ N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> f <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 <br /> in Compliance-No Violations o <br /> Q Q Other:§ n_ fi <br /> Comments (c�jOv�S it e: A",C,C\ 315 lis . 10--)ry'-q 41,01Q , an 1 1 r <br /> CMVC, -i0 ,(gAXA,P. 1 h i tk k naft.tP <br /> -13 <br /> C,,XVNCNC-� Fl7r� <br /> Inspection Form Included: Q 6� rayl��� <br /> Comments Included: ® � "CJL/7-- <br /> Business Rep Signature Phone Number Intor's Signature Phone Number <br /> L <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: EXAM P E 1 12131 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © 0 <br />