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Waste Tire Sf&my & Inspection Repoitspection Report Number <br />State of California <br />CalRecycle I 1 -1176549 <br />CalRecycle 181 (Rev. (Cal 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 -+ 7 7- r� I Inspection Type (Fill one) <br />Site Suffix: ` * Routine 0 Re -inspection 0 Referral 0 Observation <br />Local If Referral, choose referral type (Fill one) <br />Identifier: 5cyy-, tt -- clrG� rl. 6 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br />Business or Facility Name Inspected By Inspector <br />�p M 5+�,C� s Co.�►-� r c� - a <br />Physical Address a_ _ _ _/� j3 <br />3,5,35- Mj 4il� �IYL�L�ICit <br />ivCA<1-cm <br />�7�dC7 / <br />Inspection Date <br />O / <br />3 1 / <br />r <br />0 <br />0 <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Time In <br />0 <br />Time Out <br />0 <br />Business Rep <br />Title <br />0 <br />/ <br />®AMe <br />0 <br />_ AM <br />nC;l <br />v CfaYIC I�Vts(X <br />0 <br />0 PM <br />0 <br />QPM <br />- - <br />0 <br />0 <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Tire Count (Whole/PTE) <br />0 <br />Other: § <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />• Active <br />0 Passenger <br />. Generator <br />0 Outdoor <br />GPS Latitude <br />o <br />0 Closed0 <br />Altered <br />0 Hauler <br />! Indoor <br />O <br />0 Inactive <br />0 Truck <br />Longitude - <br />0 Planned <br />0 OTR <br />0 End -Use <br />0 Container <br />Business Type (Fill all that apply) <br />1 <br />0 New Tire Dealer 0 Auto Repair <br />0 Trucking Fleet <br />0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br />0 Used Tire Dealer 0 Auto Body <br />0 Car Dealer <br />0 Collection 0 Crumb Rubber <br />0 Service Station 0 Hauler <br />0 Agriculture <br />0 Shredder 0 Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />--- <br />A <br />--- --- _...-- -.... ----- --....... _..... . <br />HAULING AND MANIFEST REQUIREMENTS <br />0 <br />_A <br />0 <br />-- <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 <br />0 <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 <br />0 <br />PRC § 42956 - Registration/Decal in Vehicle <br />0 <br />0 <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 <br />0 <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />0 <br />0 <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />0 <br />0 <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />0 <br />0 <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 <br />0 <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 <br />0 <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />0 <br />0 <br />Other: § <br />CommentsGLd�i1�rZ. hSC�ra�-. UvU TV�f L /^�r1X.t. <br />ENFORCEMENT STATUS <br />0 Notice Of Violation 0 Extension <br />Compliance Deadline <br />Datem/m <br />(Required for NOV or EX7) <br />0 Referred / CalRecycle Enforcement <br />I® In Compliance - No Violations <br />Inspection Form Included: 0 X_L� <br />Comments Included: 0J— 't "^ ��g � 6 <br />Business Rep's Signature Phone Number Inspector's Signature Phone Number <br />INSTRUCTIONS ON BACK Correct: Incorrect: ( E X A L E 1 2 3 62081 <br />White Copy: CalRecycle Yellow Copy: Operator Pink C py: <br />W <br />W <br />