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Waste Tire F vey & Inspection Repo Inspection Report Number <br /> CalRecycle State of California I 1 - 1176610 <br /> CalRecycle 181(Rev. y(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 /> I <br /> TPID- 2 _ © f Inspection Type(Fill one) <br /> Site Suffix: y / ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: - Gcwl --'"��zCi�,1 tti, Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - - —"--- - - - <br /> Inspected By Inspector <br /> G.VW� I Y1 tiG�< t CVS S CVy1[ <br /> PhC (� ? O <br /> ysical s Addres (J I - <br /> 02 s'q -- <br /> Inspection Date1:2 <br /> �,IL I'1 C Cf S Zp 6 / <br /> Time In Time Out <br /> Business Rep Title�1 C Q a 0 AM 0 AM 0P Q 9P <br /> -- —- -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) -7Z (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger # Generator Q Outdoor <br /> O <br /> GPS Latitude Q Closed Q Altered Q Hauler ® Indoor <br /> 0 Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q 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 /> �- <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other S�L& S <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> -__.. __ <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> __ - _...:_.- _-- _ _ _ Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956- Registration/Decal in Vehicle <br /> QQ 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> F11 / F11 / m <br /> Q Q 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 <br /> (Required for NOV or EXT) j 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 /> 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 <br /> Q Q Other:§ - <br /> Comments <br /> ,ncT2czoW6c4-- _.mss dCztA- '4'a - <br /> ld_r.e s -- <br /> nspection Form Included: Q <br /> Comments Included: <br /> go z zz r3yc:� <br /> BjWess Rep's Signatu Phone Number nspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: x � �/ I I E I X I A I M I P L E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />