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Waste Tire S. ey & Inspection Repor. nspection Report Number <br /> Cal Recycle State of California I 1 - 1176515 <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- b q - © Inspection Type(Fill one) <br /> Site Suffix: ; / Q Routine Q Re-inspection ® Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CalRecycle Q Complaint ® Educational Visit Q Other <br /> Business or Facility Nameol - <br /> ��''�� ff �� Inspected By Inspector <br /> V <br /> 1/ Q l,l,(S d GrYI'1 wl'.e2[s ( f 1 ft 3 C <br /> Physical ddress f C1 f A. _ 4 13L`!f <br /> z Lf.So l(' 1�c.l-c,-loo P'd . �L <br /> � <br /> Inspection Date�C�efv Cj <br /> 0S <br /> aTime In Time Out <br /> Business Rep Title O AM O AM <br /> 0 1 O a *PM D ` • CIO ® PM <br /> - <br /> --- - -- -- - - - - Operational Status Tire Type Business Role Storage Type <br /> / (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> ® Active ® Passenger ® Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned - ()-OTR-— Q End=Use --C-ontainer <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 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 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 m / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> (Required for NOV or EXE <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> ti <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 /> 0 Q Other:§ ,' _i <br /> Comments 1��L.��.ffr.Yia.� ;V <br /> C% u <br /> Inspection Form Included:_0 <br /> Comments Included: 91r<1 <br /> (AP 7 Y 6 9--C) 3 <br /> Business Rep nature Phone Number nspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: 62081 <br /> TE X A L 1 2 3 <br /> L__ -_--- � � � <br /> White Copy:CalRecycle Yellow Copy:Operator Pink opy: <br />