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® 02 Waste Tire SWey & Inspection Rep®rkolnspection Report Number <br /> CalRecycle State of California �q T q — ,y A A 2 5 1 1 <br /> CalRecycle 181(Rev.y(Ca] Survey Form _ Page 1 1! 1 .1p. 'LJ �f14 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) V � v e��ii 1,1 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: _f ® Routine Q Re-inspection Q Referral Q Observation <br /> Locale, <br /> Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> �' I �� If Referral,choose referral type(Fill one) <br /> Identifier: S(�� J b� LI <br /> Business Eor Facility Name <br /> Inspected By Inspector <br /> n <br /> - � � � L� <br /> Physical Address -�-v h <br /> Us4(:) S, <br /> Inspection Date t Q / Q a / <br /> Jt� Time In Time Out <br /> Business Rep Titl�e� �1y S c O AM _S S Q AM <br /> �1 f1 v A I'1 1ilQ,� 1 tl`.�f/��A- u1Pur" l J ® PM A PM <br /> � <br /> IJ <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 /> lJ ® Active Q Passenger ® Generator ® Outdoor <br /> GPS Latitude 0 Closed Q Altered <br /> Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude — Q Planned Q OTR Q 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 /> 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 S14-ril'OJcVI &IV) Sor1n (� <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 /> Q Q 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 EXE 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 ®In Compliance-No Violations o <br /> Q Q Other:§ 1-Comments n ,2111(W, �L�j5t 1r ( onA_ on fil^ -A J�Z_ Ck ilk 7f 2, <br /> inC bnU1 A)ltnIA <br /> Noy;ocA_T e z4 csf concern. <br /> Inspection Form Included: Q <br /> Comments Included: y 0 <br /> Bt.Ysiness Rep's Signature Phone Number / Insp or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: E A P E 1 2 3 62081 <br /> M <br /> 0 White Copy:CalRecycle Yellow Copy:Operator Pink Co y:L <br />