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Waste Tire & Inspection Reppection Report Number ■ <br /> State of California <br /> CalRecycle 11 - 1176502 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <br /> Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey_Surv _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> --- - ---------- ---- <br /> TPID- (� ' O Inspection Type(Fill one) - - - -- - <br /> Site Suffix: ` * Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local r' If Referral,choose referral type(Fill one) <br /> Identifier: ��(� JQ P�S'�l,(�j r� (ol".f(h 0 CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 Inspected By Inspector <br /> ®i&ro 0 nck cg� o In i 0�, 2 <br /> Physical Address J 1 - I ^V I <br /> �0 5b D11a"-WnA cj_ <br /> C4 Inspection Date � � � 1 <br /> oon C �S�,nS 1 J <br /> Time In Time Out <br /> Business Rep Title O AM 5 O0 AM <br /> c O QPM 0 PM <br /> Mo,s �� ��`1 u''S �� J� +`,�� Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 2 0 0 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> J V ® Active Q Passenger 0 Generator 0 Outdoor <br /> O Q Closed 41 Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive O Truck <br /> Longitude - 0 Planned ® OTR O End-Use 0 Container <br /> Business Type(Fill all that apply) _ <br /> 0 New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader 0 Dismantler Q Tire Derived Fuel <br /> 0 Used Tire Dealer Q Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station Q Hauler • Agriculture Q 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 /> O O 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 / m / m <br /> O O 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 EX7) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q 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 /> Q Q Other:§ <br /> z <br /> Comments T11' t ; neriof (A'4 <br /> N <br /> �A rn5 n�'ks�a'- <br /> U i 0 i u_P c A,-5 LcN)C,ern <br /> Inspection Form Included: <br /> Comments Included: �r'sSiigjnatu,I ess Rep's gnaturePhone Number Inspe Phone Number <br /> ---- - - - - ------ -- - - - ------------------ - ---- <br /> 62081 <br /> INSTRUCTIONS ON BACK [C rect:0 Incorrect: E X A M 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop :L © ■ <br />