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Waste Tire Su. Jey & Inspection Repori Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 1196553 <br /> CalRecycle 181(Rev. (Co 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: l 3 0 Routine -4&Re-inspection Q Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: (Tocq ( Uo 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name ` Inspected By Inspector <br /> 'C41 <br /> t <br /> 1 1 d 1 ��� <br /> Physical Address 3 <br /> \�til �.,�v,r���� fir, <br /> Inspection Date c> l / I b / ` <br /> S ImC�w�v\ yl Time In Time Out <br /> Business Rep Title C> 10 AMG O AM <br /> �'�` r. 0 PM d • S S 0 PM <br /> i{C� ` Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 1 G (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®.Active 0 Passenger 0 Generator Q Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive Truck <br /> Longitude - 0 Planned OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair if 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 0 Extension <br /> 0 O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> 0 O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <br /> 0 O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> a <br /> 0 Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 2 <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> 0 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators .In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments Yy,nFOW <br /> 14 <br /> �7 Y\, <br /> Inspection Form Included: 0 D4 L��(O-25 -� _ <br /> Comments Included: 0 ��^�2 <br /> Busin s Rep's Signature Phone Number Inspectors Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: jEjXjAjM� PjLjEj 11 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © 0 <br />