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Waste Tire Seiey & Inspection Repore Inspection Report Number <br /> cal Recycle State of California I 1 - 1226531 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <br /> Survey Form - 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 Type(Fill one) <br /> Site Suffix: S C) / ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �cVn -1-czct��5 to l un�-� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name !l Inspected By Inspector <br /> Physical AddVess <br /> �u (� �f�(712©cL� <br /> �y - / C� l <br /> Inspection Date <br /> �fr rr» �I 'S21 T <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> G 3 ® © ® PM C) ® PM <br /> -- - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 0 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger ® Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned ® 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 -law <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 m <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 EXT) N <br /> a <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 /> 1010 Other:§ _ <br /> Comments <br /> /"�'�LfAS-�!'L+y l h���at,7nn.s �'( ��vE�c..� ��,rn�f �Z'Jr. ��-°_s'►---� �, <br /> Inspection Form Included: Q <br /> Comments Included: 0 <br /> Business Rep's Signature P �neber nspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect: ( EXAM E 12 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy: © ■ <br />