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..,._. <br />= , <br />Waste Tire Survey & Inspection Repo pinspection Report Number ■ <br />CalRecycle State of California I 1-1176470 <br />CalRecycle 181(Rev.(Ca[ Survey Form - Page 1 <br />Dept. of Resources Recycling and Recovery (CalRecycle) RI III= nR RI ACK INK PEN <br />Part A - Surv_ey_.__ <br />Business Profile <br />Inspection Details <br />TPID - j <br />Site Suffix: 3 8 8 6 t) Q t <br />Inspection Type (Fill one) <br />♦ Routine Q Re -inspection Q Referral Q Observation <br />if Referral, choose referral type (Fill one) <br />Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br />Local <br />Identifier: sCily\, �� lr(JL/t V <br />Business or Facility Name <br />Inspected By inspector <br />ff <br />o '' ebco u �o W .1__riL <br />Physical Address <br />'3 Gj - O i'U7�� �-t-►�t11 L iOV �C <br />/6159-U2 <br />CA 61`�C 9-� <br />Business Rep Title <br />t_ytI A 'vw � <br />Tire Count (Whole/PTE) G a <br />Inspection Date / t 1. 1 1 <br />l <br />Time In Time Out <br />AM ® AM <br />DO PM / `� O PM <br />Operational Status <br />(Fill one only) <br />Active <br />Q Closed <br />Q Inactive <br />Planned <br />Tire Type <br />(Fill all that apply) <br />40 Passenger <br />Q Altered <br />Q Truck <br />Q OTR <br />Business Role <br />(Fill all that apply) <br />® Generator <br />Q Hauler <br />Q End -Use <br />Storage Type <br />(Fill all that apply) <br />0 Outdoor <br />Q Indoor <br />Q Container <br />O <br />Latite O <br />tLongitude:-0 <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader 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 Q Other <br />Part <br />B - <br />Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />ENFORCEMENT STATUS <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />V <br />Q <br />Q <br />Q <br />Q <br />Q <br />Q <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />/ / <br />Date m m <br />(Required for NOV or EX7) <br />Q <br />Q <br />Q <br />Q <br />Q <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />PRC § 42956 - Registration/Decal in Vehicle <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />Q <br />Q <br />Q <br />Q <br />Q <br />Q <br />Q <br />Q <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />Q Referred / CalRecycle Enforcement <br />In Compliance - No Violations <br />Q <br />1 Q <br />1 Other: § <br />Comments <br />I <br />Inspection Form Included: Q <br />Comments Included: <br />eusi ss Re 's Signature Phone Number In ctSignatur _ Phone Number <br />-- ---- 62081 <br />INSTRUCTIONS ON BACK Correct: Incorrect: lj % E X A P 1 2 3 <br />0 <br />White Copy: CalRecycle Yellow Copy: Operator Pink Cody. T <br />■ <br />N <br />0 <br />W <br />W <br />