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Waste Tire Survey & Inspection Report <br />CalRecycle State of California <br />Caycling le 181 (Rev. y (Cal Survey Form - Page I <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />0—+A-e..r—, <br />Inspection Report Number ■ <br />I1 -1177823 <br />RLUF OR RLACK INK PEN <br />Business Profile <br />Inspection Details <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />TPID - S 1 1 (6O LA- Q F <br />Site Suffix: "1 I <br />Inspection Type (Fill one) <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />I* Routine Q Re -inspection <br />Q Referral <br />Q Observation <br />Local <br />Identifier: �a(� JO(J1 CC')t t,�1+t/� <br />If Referral, choose referral type (Fill one) <br />fi1�I <br />1 <br />Q CHP Q CalRecycle Q Complaint <br />Q Educational <br />Visit Q Other <br />Business or Facility Name <br />Inspected By Inspector <br />Q <br />Q <br />�d� r � <br />6us���11 sued <br />Physical Ad ress <br />- o ► <br />CSc <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />1 SS o o McJ;;nel v <br />Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q <br />1^ C1� �533p <br />L r0 <br />Inspection Date <br />_i <br />Q <br />J <br />a- 1 <br />P <br />Time In <br />Time Out <br />Other: § <br />Business Rep Title <br />Q O AM <br />O AM <br />Q <br />1 <br />To o �QI`I 1SViA © �l tf1S ftC. <br />0 PM <br />0 PM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Nj <br />Tire Count (Whole/PTE) ^ <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />j„ <br />® Active <br />Q Closed <br />Q Passenger <br />Q Altered <br />® Generator <br />Q Hauler <br />® Outdoor <br />Q Indoor <br />O <br />GPS Latitude <br />O <br />Q Inactive <br />® Truck <br />Longitude_ - _ _ _ _ _ _ - <br />_Q -Planned - <br />Q OTR <br />Q End -Use <br />Q Container <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair ® 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 <br />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 />n <br />n <br />Other: § <br />Comments <br />UJ U 5 _n_OVC & <br />N rn b 5 c e..Jern.S nT r nr fie( n <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Datem/ M / <br />m <br />(Required for NOV or EX7) <br />Q Referred / CalRecycle Enforcement <br />0 In Compliance - No Violations <br />Inspection Form Included: Q la, � <br />Comments Included: 4 �'� ��/�� aaq qbf `JL <br />usines ep Signature Phone Number Inspe is Signature Phone Number <br />INSTRUCTIONS ON BAC Correct:0 Incorrect: IEIXIAIMIPILIEI 1112 3 62081 <br />White Copy: CalRecycle Yellow Copy: Operator Pink Copy: LEA ® ■ <br />