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M Waste Tire Su,vey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of cle181(R I 1 - 1210488 <br /> CalRecycle181(Rev.y(Ca) Survey Fora - 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- f� Inspection Type(Fill one) <br /> Site Suffix: y -1 `J Q Routine Q Re-inspection Q Referral Q Observation <br /> LocalC -1-0 <br /> If Referral,choose referral type(Fill one) <br /> n V <br /> Identifier: S(► BU'�U` �1 l-U'1�f1'f Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address - �S 0 <br /> - <br /> \�, Inspection Date / a- 3 / 3 <br /> �j�auYU�b� GSZ1� <br /> Time In Time Out <br /> Business Rep Title O C AM 1 f V S ® AM <br /> �lo�k� J O PM ` 3 J O PM <br /> CnU s11�� S�'1 U <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 /> t Active ® Passenger S Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> o Q Inactive S Truck <br /> Longitude - Q End-Use Container <br /> Q Planned Q OTR <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 ® Other ,u_ <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 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 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 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX T) N <br /> _ a <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 /> 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 /> Q Q Other:§ <br /> Comments ` <br /> Q 1�,n�.� �rx�.c,���, � an s(�t� �� • l�-in��-tom,. �.. <br /> -A' <br /> 04Vied s Wim- e <br /> Ao w u*51A4 ckS4",c t u `r lqt Li, <br /> Inspection Form Included: Q 1 <br /> Comments Included: <br /> Business Rep's Sign re Phone Number Insp tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A M P 11213 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:L <br />