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Waste Tire Su. Bey & Inspection Report ,nspection Report Number ■ <br /> Cdecycle State of California I 1 v 1242327 <br /> CalRecycle 181(Rev.y(Cal Survey Form - Page I <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- i r_ � a � O ^ _ Inspection Type(Fill one) <br /> Site Suffix: I 1Q l ( I* Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: s(�(��/y>u�j ^ �(�lA,(��� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name _ _I <br /> I ' <br /> iNYInspected By Inspector <br /> I s N <� 5� 0PQ <br /> Physical Address 3 1 <br /> Inspection Date `7 <br /> Time In Time Out <br /> Business Rep Title \ ®AM AM <br /> ` S 0 PM ' 0 PM <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 /> IS Active • Passenger 0 Generator ® Outdoor <br /> O Q Closed Q Altered <br /> ��� Latitude _ 0 Hauler Q Indoor <br /> o Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> * New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station ® 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 I HAULING AND MANIFEST REQUIREMENTS <br /> Q Q - �Notice Of Violation Q Extension <br /> 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 /> QO 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date 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 (Required for NOV or EX7) n <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> Q 0 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 Q Other:§ <br /> Comments <br /> W[l142 V'34n,�lSl, 'Insv1t, onA)r11Ce. <br /> Inspection Form Included: Q <br /> Comments Included: ® <br /> Busnfersjs Rep's Signature Phone Number Insp c or's Signatto Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A M JgE I I 112 j 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink C y. ■ <br />