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Waste Tire S&ey & Inspection Repor Inspection Report Number <br /> State of California <br /> CalRecycle I - 1176590 <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- Inspection Type(Fill one) <br /> Site Suffix: I S I 5 L ( ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Swy1 -TV4jW^, IC,4AAAAA­", 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility <br /> 1Name — Inspected By Inspector <br /> �et(� <br /> Physical Address - L (� 1 <br /> ' N <br /> Inspection Date <br /> �f ti'r✓lG� ��wvf� �r'T 15:�S/ <br /> Time In Time Out <br /> Business Rep Title AM _ 6 AM <br /> J r QO PM I Q 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 /> 8 0 Active 0 Passenger • Generator 0 Outdoor <br /> 0 <br /> G pS Latitude 0 Closed 0 Altered 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 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 ,Z / <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> 0 I 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance-No Violations /K <br /> LoLl § <br /> Comments Jf I ` 43 <br /> 4 1 <br /> c1Lt�i17-ate I nspce�Y� t%s C eA t&t Cz&0 tAo .F-F3ILC W)LVlS \ <br /> Inspection Form Included: 044:�& <br /> Comments Included: I-/ <br /> Phone Number 'Inspector's Signature_ _ Phone Number <br /> INSTRUCTIONS ON BACKCorrect:0 Incorrect: � V JMXJAJ 1 M 1 I 2 1 3 1 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop :L <br />