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Waste Tire Sugey & Inspection Repo <br /> rilill. Inspection Report Number <br /> State of California <br /> CalRecycle 181(Rev. (Cal <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 I 1 - 1255849 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- O Inspection Type(Fill one) <br /> Site Suffix: 1 'S Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: v�� C��y� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Onra„ «C• Inspected By Inspector <br /> 7)z> T T <br /> Physical Address <br /> ��� S �• C�t�.c�c ��� <br /> C Zb� Inspection Date o / Z 6 / I <br /> �/ <br /> �Co Time In Time Out <br /> Business Rep Title ' 5 l 0 AM 2 0 AM <br /> n S 0PM 2 L V 0PM <br /> Yam (row.e,Z S• �. <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active • Passenger OGenerator Q Outdoor <br /> Q Closed 0 Altered A) � C <br /> GPS Latitude 9 Hauler Q Indoor <br /> O Q Inactive 9 Truck <br /> Longitude - Q Planned OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 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 • Hauler Q Agriculture Q Shredder 0 Other <br /> '^ <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> �Notice Of Violation Q Extension <br /> Q Q <br /> 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 <br /> m / <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Fi <br /> Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <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 Q In Compliance-No Violations o <br /> Q Q Other:§ <br /> ` 1 z <br /> Comments�o 1,,k_-VI-Q- (tJC_S\� 2Cpy\ CoY. <br /> Q �ol�w;rC w SS h e,kg&- <br /> S <br /> Inspection Form Included: Q <br /> zo9-Y68'�8 <br /> Comments Included: <br /> Business Rep's Signature Phone Number lnspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E�XJA�M� PJLJEJ 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />