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02 Waste Tire Su, Bey & Inspection Report <br />State of California <br />CalRecycle <br />CalRecycle 181(Rev.(Cal Survey Form - Page 1 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />Part A - Survey <br />Inspection Report Number <br />I1 -1210237 <br />BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />TPID - 1 kA 2 q 1 -7 _ O Inspection Type (Fill one) <br />Site Suffix: 0 Routine 0 Re -inspection 0 Referral 0 Observation <br />Local <br />r <br />Identifier: YN 00.Q(U Y'% � <br />Business or Facility Name `t <br />1� Om S�e�� S cam; c�S <br />Physical Address <br />3 S 35 �.. M•�ck� S� . <br />S �0.✓k\-oy, r °I52d. <br />Business Rep Title <br />©Qecc���o�nS <br />Cesdc YNR.2 -- Mu.rosj,e(- <br />Tire Count (Whole/PTE) 7 <br />O <br />GPS Latitude <br />O <br />Longitude - <br />Business Type (Fill all that apply) <br />0 New Tire Dealer 0 Auto Repair <br />0 Used Tire Dealer 0 Auto Body <br />0 Service Station 0 Hauler <br />9 Trucking Fleet <br />0 Car Dealer <br />0 Agriculture <br />If Referral, choose referral type (Fill one) <br />0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br />Inspected By Inspector <br />3 - 1 ATT v <br />Inspection Date 6 / --2— 6 / ` 3 <br />Time In Time Out <br />. 1 <br />2 . <br />0 AM <br />0 O PM <br />Operational Status <br />Tire Type <br />(Fill one only) <br />(Fill all that appl <br />Active <br />0 Passenger <br />Closed <br />0 Altered <br />0 Inactive <br />0 Truck <br />0 Planned <br />0 OTR <br />0 Government <br />0 Collection <br />0 Shredder <br />0 Retreader <br />0 Crumb Rubber <br />0 Other <br />0 AM <br />-* PM <br />Business Role . Storage Type <br />(Fill all that apply) (Fill all that apply) <br />0 Generator 0 Outdoor <br />0 Hauler 10 Indoor <br />0 End -Use 10 Container <br />Dismantler ( ) Tire Derived Fuel <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />ENFORCEMENT STATUS <br />V <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />Notice Of Violation Extension <br />0 <br />0 <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 />Compliance Deadline <br />PRC § 42956 - Registration/Decal in Vehicle <br />0 <br />0 <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Date <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 />(Required for NOV or EXTJ <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 Referred / CalRecycle Enforcement <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 />In Compliance - No Violations <br />0 <br />0 1 <br />Other: § <br />Comments <br />C0VV e_C V\ <br />Inspection Form Included: �rG�9/� _- <br />6,51-3 �..(�J 2c�L1��•3z9 <br />Comments Included: JAAAA 9513- <br />B s ep s Igna u hone Number Inspector's Signature Phone Number <br />INSTRUCTIONS ON BACK Correct: 0 Incorrect: � 1W EXAMPLE 1 2 3 62081 <br />White Copy: CalRecycle Yellow Copy: Operator Pink Copy: LFA <br />