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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of California 11 - 1210460 <br /> CalRecycle 181(Rev.y(Ca)' 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- m Inspection Type(Fill one) <br /> Site Suffix: Q 3LA 3 lJ * Routine Q Re-inspection Q Referral Q Observation <br /> Local1 �� �� If Referral,choose referral type(Fill one) <br /> Identifier: ��n J0 L"f1 \ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Fdd_r4SA-V_ 3 - (� � S c)Physical 9 G Z,�� <br /> 1Inspection Date 1 i ' 3 <br /> Is c0 k�,, CA �i sZ1s <br /> Time In Time Out <br /> Business Rep 1- Title(� p ^ � � �AM � : p � 0 AM <br /> �f U�15 "CR, 1.\� .l . S PM 1_,11 S a PM <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 Q Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 411 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 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 /> 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 /> 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 <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 /> 2 <br /> W <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <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:§ <br /> Comments <br /> {�,J�7- �je_Q -j <br /> E� <br /> Inspection Form Included: Q <br /> Comments Included:W <br /> Bus ess R p' Signature Phone Number Insp is Signature hone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:10 Incorrect: E X A 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co y: <br />