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r � <br /> Waste Tire Su. ✓ey & Inspection Report Inspection Report Number ■ <br /> cal Recycle State of California 11 e 1210104 <br /> CalRecycle 181(Rev.y(Cal 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 /> Site 71- I O � _ 1 Inspection Type(Fill Fill one) <br /> Site Suffix: Routine Re-inspection Referral Observation <br /> Local t. If Referral,choose referral type(Fill one) <br /> Identifier: h J QO`4 V�� �vy� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 Inspected By Inspector <br /> Physical Address <br /> �S\2 <br /> Inspection Date � � Z 2 <br /> `C_C�C K vor C GS2 I S <br /> Time In Time Out <br /> Business Rep Title 5 O AM 2 C O AM <br /> m <br /> YA. aq_ <br /> ' S � PM � J / 40 PM <br /> Dob ����CC7 1 Mai - <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 /> 5 40 Active Q Passenger • Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O Q Inactive 40 Truck <br /> Longitude - Q Planned I& OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader 0 Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber t. <br /> Q Service Station Q Hauler Q Agriculture Q Shredder • 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 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <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 (Required for NOV or EXT) <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 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> Q Q1 Other:§ <br /> Comments 1t? `\1�s e_ <br /> �\A e__ %Ao \ <br /> oc cep.-s c�(Cov.cec v-%- <br /> Inspection Form Incl ed: Q Z-��A 14���X <br /> Comments Inclu ' es !•-���/� .�� cL �/`%� 2O��y6�-32g�1 <br /> Bu p s Signature Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTION ON BACK Correct:0 Incorrect: X j� VIIEIXIAIMIPILIEI 1112N 62081 <br /> . White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />