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Waste Tire Survey & Inspection Report Inspection Report NumberState of <br /> ■ <br /> CalRecycle CalRecycle1ifornia 181(Rev.10/10) <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 I1 - 1210409 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- t >� O Inspection Type(Fill one) <br /> 1 <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local I If Referral,choose referral type(Fill one) <br /> Identifier: 1,r) OLk� <br /> _ 50.f1 J 0�(u Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ` b Inspected By Inspector <br /> � �Dr1 � � Ilirl� f <br /> Physical Address 3a I _ I O <br /> 3aC) S_ S�o(,Ltb, St. <br /> Ct S_- ^6 Inspection Date 1 1 3 on XJ <br /> Time In Time Out <br /> Business Rep Title 0 AM C 0 AM <br /> AY)n0IN V r" <br /> IZA%,r� { MUl,t< qf` 5 0 PM `�' ® PM <br /> - - --- - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> 0 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active ® Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive * Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® 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 I& Other K)'1 1 <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 /> QQ 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / Ffl / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> Q 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 /> Q Q Other:§ <br /> Comments 1 C.J.lo Cel JI'A 1 C — <br /> i f tom_ �1`lJI S -CtJ <br /> J (�o til OJA16ti!�t Co S u. tlL(u", L4 4x)Zra.Cn- - <br /> Inspection Form Included: Q <br /> Comments Included: <br /> 99 X05 Lt g 31 <br /> Business Rep's Signature Phone Number Insp tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: >� EJXJAJ It 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy: ® 0 <br />