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Waste Tire Su. dey & Inspection Report Inspection Report Number <br />■ W YA�iYyYlri State of California e ■ <br />CalRecycle 181 (Rev. y(Ca) Survey Form Page 1 I1 1210578 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />)art A - Survey BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />TPID - Inspection Type (Fill one) <br />Site Suffix: 6 '9 o 0 j o <br />(� ( ® Routine 0 Re -inspection Q Referral Q Observation <br />Local SGL>2 J 6Ge`� �� Aldentifier: Ge�t�t/l' <br />Business or Facility Name <br />�!'V rc_Y . A -LD et V1 <br />Physical Address <br />301 s - IF --c <br />Business Rep1� <br />cwnto" �jo NtilkO <br />Tire Count (Whole/PTE) <br />GPS Latitude <br />If Referral, choose referral type (Fill one) <br />Q CHP Q CalRecycle Q Complaint 0 Educational Visit Q Other <br />Inspected By Inspector <br />1t <br />Z 1 Z 1� U�4 <br />Inspection Date 9' / C) --7 <br />Time In Time Out <br />Title 0 AM <br />e— / 0 - .rZ C> 0 PM <br />Operational Status Tire Type <br />(Fill one only) (Fill all that appl <br />® Active 40 Passenger <br />O 0 Closed O Altered <br />O Q Inactive O Truck <br />Longitude - 0 Planned O OTR <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair 0 Trucking Fleet Q Government 0 Retreader <br />0 Used Tire Dealer Q Auto Body Q Car Dealer O Collection O Crumb Rubber <br />Q Service Station 0 Hauler Q Agriculture O Shredder Q Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />O <br />0 <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />O <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />O <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <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 />Q <br />O <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />0 <br />® <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />0 <br />O <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />O <br />O <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />O <br />0 <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />O <br />Q <br />Other: § <br />Comments <br />0 AM <br />Lt6 0PM <br />Business Role Storage Type <br />(Fill all that apply) (Fill all that apply) <br />® Generator Q Outdoor <br />0 Hauler 10 Indoor <br />Q End -Use 10 Container <br />® Dismantler Q Tire Derived Fuel <br />Inspection Form Included: V <br />Comments Included: <br />Business Rep's Signature Phone Number s ct S', <br />INSTRUCTIONS ON BACK [Correct: 0 Incorrect: I EXAM <br />■ White Copy: CalRecycle Yellow Copy: Operator Pink Copy: LEA <br />ENFORCEMENT STATUS <br />O Notice Of Violation O Extension <br />Compliance Deadline <br />Date/m/m <br />(Required for NOV or EXT) <br />O Referred / CalRecycle Enforcement <br />In Compliance - No Violations <br />Phone Number <br />62081 <br />® ■ <br />