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Oa Waste Tire Survey & Inspection Report inspection Report Number ■ <br /> State of California <br /> CalRecycle 11 - 1177859 <br /> CalRecycle 181(Rev.y(Ca] Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Fart A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � Q Q Inspection Type(Fill one) <br /> ISite Suffix: Is Routine Q Re-inspection Q Referral Q Observation <br /> Local ) / If Referral,choose referral type(Fill one) <br /> Identifier: S01 _T)u �,1 ( 0QIn Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name "� ��� <br /> L Inspected By Inspector <br /> Tf" <br /> Physica�Address31 <br /> zcck � <br /> �SI"7G Inspection Date 1 / 0 � 1 <br /> L� CI <br /> Time In Time Out <br /> Business Rep Title l r 0 AM ` 0 AM <br /> 1 ,l J V <br /> 46 PM 1 I O QPM <br /> Vv <br /> N L e4 M�Pu1 <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 /> ® Active Q Passenger • Generator Q Outdoor <br /> GPS Latitude Q Closed Q Altered <br /> Q Hauler ® Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / 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 EJC <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 /> 2 <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q 014 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> Q Q Other:§ <br /> 1I ].� 1 <br /> Comments lfcr�A� C12 � _S�Z1��f a��4oil_(}C <br /> No ��nji-onS h1 <br /> Inspection Form Included: Q <br /> Comments Included: ® 'U <br /> Business Rep's Signature Phone Number Inspe is Signature hone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E XA rP El 11 1 2 1 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink C y A ■ <br />