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M 0 Wbste Tire Su. tey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California F� I 1 1210546 <br /> CalRecycle 181(Rev.y(Cal S rvey Form <br /> - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) F�9�!d 9 M�i u 1 1, <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Inspection Type(Fill one) <br /> Site Suffix: 46 Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier. �a^ �V� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> - - - <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address QA <br /> 3OCS S c �eC\K W_O-V_ V—OC'V <br /> Inspection Date S / 2 Z / ' 3 <br /> Ldc�� C� �S2�lU v <br /> Time In Time Out <br /> Business Rep Title 0 AM c AM <br /> ` 1 ` 1 J QPM <br /> �rG IAc�Ct��`�ca� ` ` 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 /> Is Active Q Passenger ® Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Indoor <br /> o Q Inactive Q Truck <br /> Longitude - Q Planned 0 OTR Q End-Use Q 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 40 Other `v(� e�Q� '��`\��'-,"-Rf <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 <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <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 /> Q Q1 Other:§ <br /> z <br /> Comments <br /> J�b 1G <br /> Inspection Form Included: Q <br /> Comments Included: <br /> Business Rep' ignature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK I orrect:* Incorrect: IEIXIAIMIPILIEI 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />