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Waste Tire Su. wey & Inspection Report inspection Report Number ■ <br /> CalRecycle State of California 11 - 1177797 <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: Q 049— Q 1 ® Routine 0 Re-inspection Q Referral Q Observation <br /> LocalV J �� cv�+� If Referral,choose referral type(Fill one) <br /> Identifier: b Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 16 <br /> Physical Address l 1 �V� <br /> ,-t s' E, lei e-r l e ov-A,v, Lvi- <br /> Inspection Date -'7 <br /> L0C�; ( C �oZztC� G <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> I O ®PM c;2- a O PM <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 /> Q Active Q Passenger ® Generator Q Outdoor <br /> O ® Closed Q Altered <br /> GPS Latitude <br /> O Q Inactive 0 Truck Q Hauler 0 Indoor <br /> Longitude – Q Planned ® OTR 0 End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government 0 Retreader Q Dismantler Q Tire Derived Fuel <br /> 0 Used Tire Dealer Q Auto Body 0 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 0 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 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date N <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle S <br /> 0 O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> a <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> uj <br /> w <br /> O Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> O O Other:§ <br /> Comments /� ° Ah;/- .`� —C_ J <br /> 9 <br /> .o,J,vte_ PYI Pc'i�YtJ�. �Y, (�0�)ti; Ylc\ 2� /Z 7c-. ,ItA, 3 <br /> n <br /> 1 o (�j�.v�wc f�z�t� tC1�hvl�. ICS <br /> /3 c�TO{i✓P.� :Z L2 .��vt��� _ 11 rte- rv,n.<' �.� C\ x{213 ��.�,_Y) <br /> Inspection Form Included: 0 �- <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number f sp ct r' ig ture Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: 'V Z' EXAM L E _ 1112 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co Y. <br /> LE �� ■ <br />