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Waste Tire Survey & Inspection Report ' Inspection Report: Number <br /> Cal Recycle State of CalRecycle <br /> 181(R 1 - 1244922 <br /> Caycling 1e 181(Rev.y(Cal Survey Form - Page <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- urvey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection� - O 1 Inspection Type(Fill one) <br /> Site Suffix: f Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: q{� OLI�LAI-, C�L�{l U <br /> J I J Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> 5 7; �- Aub _ �+ <br /> Physical Address ll-- 3 I l V 5 w`S`S0 <br /> X533 S_ �� c���'o�• J T- -- <br /> LA Inspection Date�Sa,�10 1 V <br /> Time In Time Out <br /> Business Rep Title 0 AM r� 0 AM <br /> t v 9P QL S OPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � � � 1If <br /> Active 0 Passenger • Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> G+P� Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned 0 OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer ® 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 j} t _ <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ®Other Ta W-(J l,t Ul L 2 j N 1 LC— <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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 m / 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 EXT) 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 /> W <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance-No Violations o <br /> Q 1 Q 1Other:§ <br /> � L z <br /> Comments Q„A C�,Q_\A f�, 1�S ��� �0 (l.� —C S " N tl� <br /> A <br /> �O aj IL-141"- b1 td I P� wn5 4 CQj rl- <br /> Inspection Form Included: Q P&F 33&)-0V1 D? <br /> Comments Included: <br /> _llusinqZep's re Phone Number Insp or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X CEJ E X A M P E 1 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy:L A <br />