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Oa Waste Tire Survey & Inspection Report - Inspection Report Number <br /> State of California <br /> CalRecycle ( 11 - 1177883 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <br /> Survey Forma m 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- Inspection_ o � Inspection Type(Fill one) <br /> �Site Suffix: o _1 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: l� 0rA IA') '� (014 <br /> _ J 1 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> wct sk'�_ (41wJ� We 3 q - I DPhysical Address CS r <br /> Inspection Date <br /> Time In Time Outl <br /> Business Rep Title 0 ® AM I C ® AM <br /> LJ V QPM J 0P <br /> 12.,cuCc�o )ok 0 <br /> — -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 1 ( (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> w <br /> '0 Adtive ® Passenger a Generator 0 Outdoor <br /> O Q Closed Altered <br /> GPS Latitude _ Q Hauler ® Indoor <br /> O Q Inactive Truck <br /> Longitude - Q Planned ® OTR ® End-Use ® 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 /> Used Tire Dealer Q Auto Body Q Car Dealer ® Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture ® 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 /> QQ 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> Ffl / m / Ffl <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle q <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 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 <br /> In Compliance-No Violations o <br /> Q 1 Q Other:§ <br /> _ � 1 ]. L ,� � }� <br /> Comments � 1t�Tc -111th ]�,kio" W1 i ' Vim'-�."Tl K��-►`� IIUL�fI�G, <br /> _ ee, rn4YY(1(S �OJ ccs <br /> Inspection Form Included: <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspect rf Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E X A L 112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cokl ® ■ <br />