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M Waste Tire F vey & Inspection Repo Inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1176625 <br /> ry <br /> CalRecycle 181(Rev. (CalRecycle) Survey <br /> 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- Inspection Type(Fill one) <br /> Site Suffix: 4 4 8 d 2 n <br /> - ® Routine Q Re-inspection Q Referral Q Observation <br /> Local (� If Referral,choose referral type(Fill one) <br /> Identifier 7r��VJ l,,cw,.�.cr Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name _ JJ Inspected By Inspector <br /> ���+c�vv�S <br /> Physical Address J 3I / �^I�'►�LUYtQ(dt .��f"��'�'� <br /> i s 1(, 1 E. ramal E RCA . <br /> Inspection Date <br /> LoC..k'e�oY--Cj C A 9 s a 3F L <br /> Time In Time Out <br /> Business Rep Title _ Q AM Q AM <br /> '-CS S ® PM S 9 PM <br /> - --- - -— -- perational 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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> GPS Latitude ® Closed Q Altered <br /> Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) MA /UTA N/A <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 ® Otheryu � ri K <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 O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle v <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities u, <br /> Q O 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 /> Inspection Form Included: QlBusiness <br /> ^Comments Included: ® v- �Za�� �6� «''s Signature Phone Number spector's Signature Phone Number <br /> INSTRUCTIONS ONorrect:0 Incorrect: I``h `=' I E X A P 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co y:LE <br />