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03 Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRec cle State of California <br /> Y CalRecycle 181(Rev.10/10) 11 - 1226353 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Survey Form - Page 1 <br /> Part A _ BLUE OR BLACK INK PEN <br /> -Survey <br /> Business Profile Inspection Details <br /> TPID- q Inspection Type(Fill one) <br /> Site Suffix: I l 519- 1 j ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SCLYX LC,�.I�l� -tel J 0 CHP 0 CalRecycle0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name (�— f Inspected By Inspector <br /> 7n--- /iyze, C4 <br /> Physical Addressr� 3 L►,y� b:, <br /> 77Gc_ � 7�J Inspection Date <br /> .� i / Com/1/) I�� •J C] L <br /> Time In Time Out <br /> Title O AM O AM <br /> Business Rep ,,,w r „� : ---?, 0 0 PM 5_ 0 PM <br /> -- mi't ���I OC��� Q(,AJr Operatiro/n`al 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 /> D 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> 0 ® 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> W <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators A@ In Compliance-No Violations o <br /> 0 0 Other:§ , <br /> z <br /> Comments <br /> J�G Co CJ zy1 r+2 -L n <br /> Inspection Form Included: 0 <br /> Comments Included: 0 -�6�'Yd <br /> Business Rep's Signature Phone Number sp tor' na Phone Number <br /> INSTRUCTIONS ON BACK Correct:a Incorrect: IEIXIAIMIPILIEI 1112 13 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />