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Waste Tire St,llrvey & Inspection Repan Inspection Report Number ■ <br /> CalRecycle State of California Aurvey Form a page [1 I l - 1242487 <br /> CalRecycle 181(Rev. (Cal <br /> Dept of Resources Recycling and Recovery(CalRecycle) S <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- _ © Inspection Type(Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> LocalL If Referral,choose referral type(Fill one) <br /> Identifier: J &<)—To ,q vt,'lr) CV t/((��in O CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 6 1 Inspected By Inspector <br /> IF �eer,os' Pc,1�� �unlPutl� � � - � � � EsC,vTYd <br /> Physic1alJAddress <br /> CIA <br /> �SZIS Inspection Date <br /> 1 Time In Time Out <br /> Business Rep Title /l ® AM (f�� h ® AM <br /> ) O PM 0 v Q PM <br /> May.r�c.�o Sc�uc:�.db . Ass;s�u�k C-d-O- <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 /> ® Active Q Passenger ® Generator Q Outdoor <br /> GPS Latitude O O Closed Q Altered A).119 <br /> Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned ® OTR O End-Use Q Container <br /> Business Type(Fill all that apply) h/`-10t <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 ® Other PSP m(AlliCACA i_ 11n <br /> 7 �— <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 0 Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> r <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CalRecycle Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators -®In Compliance-No Violations o <br /> O 1 O 1Other:§ <br /> L 1 - <br /> Comments eA 41 <br /> ra, LA34 <br /> 57 r`� l �a !v^ )-\L 1):n � tr s ! L CA-CIA Tkd _ <br /> N O VlbA�'ons Of CAfc.{AZ, rte c-011CUn. <br /> Inspection Form Included: O' a <br /> Comments Included: SO '' S l- ( f� <br /> Busi ep's Signature Phone Number %inig-nature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect: g E X A M L 1 2 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy: ® ■ <br />