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02 Waste Tire Su ey & Inspection Report -nspection Report Number . <br /> CalRecycle State of California I 1 - 1178021 <br /> CalRecycle 181(Rev.y(CalRecycle) Survey <br /> Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey <br /> BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: `� "� l lJ 4§ Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local \�ul� / u'�� If Referral,choose referral type(Fill one) <br /> Identifier: �'�� �.J ( ) 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business r Facility Namel l Inspected By Inspector <br /> tem, �1 al �Su to i cY� Q _ <br /> Physical Address 1 101 IEs(A 0 <br /> 30131 5 - �w _ 33 V <br /> Inspection Date / / ) <br /> ISSM Time In Time Out <br /> Business Rep Title 1 s 0 AM 0 AM <br /> N -3' 011 �,� `,t,St&(c I . 5 J 0 PM '� O 1h PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ri (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active 0 Passenger 0 Generator ® Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler • Indoor <br /> O 0 Inactive 40 Truck <br /> Longitude - 0 Planned ® OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) Ur <br /> 0 New Tire Dealer 0 Auto Repair 40 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 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / 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 EXTJ N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 O In Compliance-No Violations o <br /> 0 0 Other:§ L ` I <br /> Comments wr��J�e, Tl-tom-- ,ISI<��n�X�( <br /> Inspection Form Include 0 ��6 677 P, ' �� �7b <br /> Comments Included: ® — <br /> n ss Rep's ig t re Phone Nu er Inspe t is Signat re Phone Number <br /> 62081 <br /> ctINSTRUCTIONS ON BACK C rct: <br /> 0 White Copy:CalRecycle Yellow Copy:Operator Pink yEA © ■ <br />