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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CalRecycle I 1 - 1242317 <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 Inspection Type(Fill one) <br /> Site Suffix: �p * Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local .,� �., If Referral,choose referral type(Fill one) <br /> Identifier: Q� J0U-gW rN WuC�f v' 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> FrG 5hv 3 9 - 1 � <br /> Physical Address l �'�`�� <br /> SWo3 CY1ero Le__e_ <br /> r CA T5a15 Inspection Date / 8 I u <br /> Time In Time Out 1 <br /> Business Rep Title /� 0 AM l 0 AM <br /> \ V 0 PM #PM <br /> 4 �'eJ� �pd1�t�U.% P��'lt.t.'j7l1 <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) S <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 3 3 <br /> ' S Active 0 Passenger 0 Generator ® Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair ® Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation Q Extension <br /> 0 0 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) n <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities u, <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments n 1 , r in <br /> I <br /> ' S ' <br /> No yl'(��`I't�S 0� CkJC4+s 14 cbnwn. <br /> Inspection Form Included: 0 <br /> Comments Included: <br /> In <br /> us' e s R p' Signature Phone Number Ins ctor's Signature Phone Number <br /> INSTRUCTIONS ON AC Vorect:0 Incorrect: M � q EXAM L 1 Z 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy: ® 0 <br />