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Waste Tire SL%ey & Inspection Repo AInspection Report Number ■ <br /> CalRecycle State of California I 1 - 1255775 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <br /> Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- ' 2 / - d .� Inspection Type(Fill one) <br /> Site Suffix: C� 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 60�Y1 'To9 6.1y) Co tz' Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name �1 Inspected By Inspector <br /> Tc rv*_. 1�%Tr sf se-c so-\eS <br /> Physical Address 39 - <br /> mz A. Lin. 1 <br /> Loa-% Cj� gS24b <br /> Inspection Date 1 ` / � 8 � 1 S <br /> l� <br /> Time In Time Out <br /> Business Rep Title 1 O AM Z O AM <br /> PM ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(WholEr/F'1 t] 67- <br /> 7- (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 40 Passenger S Generator 40 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude 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) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q 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 /> 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 m <br /> Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXTJ N <br /> Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <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 /> 010 Other:§ <br /> Comments <br /> S CGw+vr.e <br /> Inspection Form Included-0� i� �y��(i1 , `60 <br /> Comments Included. <br /> Business Rep's Signature Phone Number Inspec is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E X A M P L E 1112 N 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />