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Oa Waste Tire SL. vey & Inspection Repon Inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1177847 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <br /> 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- 1 ' O Inspection Type(Fill one) <br /> Site Suffix: # Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: SAY,% noel >n!I I^ l(�LLn� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 Inspected By Inspector <br /> S e c rs U o (P-4,_r 3 - 1 ► r ]�� <br /> Physical Address <br /> _13S b N ck,c c _ — W <br /> AInspection Date � / � � / � 3 <br /> Time In Time Out <br /> IN4 <br /> Business Rep Tittle]. I U O AM O AM <br /> t0)(1 fl C�c_ 0 4r-, (�. ® PM ® PM <br /> - <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 /> 0 Active ® Passenger • Generator Q Outdoor <br /> Q Closed Q Altered <br /> Cid$ Latitude Q Hauler 10 Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTI3 Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> ® 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 <br /> ® Service Station Q Hauler Q Agriculture Q Shredder Q 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 /> 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> Q 1* 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 EXT) N <br /> r <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 /> 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 1 Q 1 Other:§ <br /> Comments <br /> 9-10Ar,,l t�je�5r1`Nl few i f1SQZfJ�o C1 ayfU�. Ort 1�+5 U.TE <br /> -F S n <br /> 771 <br /> Inspection Form Included: Q <br /> Comments Included: <br /> Busin s Re nature P e Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BAC Correct:* Incorrect: E X A M . 1 2 3 62081 <br /> ® to Copy:CalRecycle Yellow Copy:Operator Pink Co y L ® ■ <br />