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Waste Tire S, iey & Inspection Repor Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1177591 <br /> CalRecycle 181(Rev.10/10) <br /> (Cal 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- 1 t , _ O ' Inspection Type(Fill one) <br /> Site Suffix: + 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: '-�h J dip v�Y1 U� t/ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other` <br /> Business or Facility Name Inspected By Inspector <br /> v aV0.9-- 9T-'0 'QC�-S - 1 O Esso �_A_o <br /> Physical Address <br /> Inspection Date Z O 1 l <br /> S�oc�fion /'AaIS2a6 <br /> Time In Time Out <br /> Business Rep Tittlle1 i AM 0 AM <br /> (�-C-� ` 10.h�/V►c� e I � 3 v 0 PM 1 2 � 0 * 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 /> • Active Q Passenger Generator Q Outdoor <br /> O Q Closed Q Altered N 1A <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned ! OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) (-k` <br /> Q New Tire Dealer Q Auto Repair Q 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 # Other ��.�s�n`o���a �n�C' /'►Tf. <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 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 iQ 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 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or E)C7) N <br /> a <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 /> Q 1 Q Other:§ , ` i,, <br /> Comments � Y44.0�k- b'o CG�Q �� TV�7� C CA_kJZ- Ccy�� N <br /> O <br /> NO ViCC)LCL i01r� (� k— COv\.Ce-r <br /> Inspection Form Included: Q 1 Own) \ <br /> Comments Included: i l �� r 9� U�� -�1 <br /> Business Rep's Signature Phone Number Inspe is Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A L E 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co y:L <br />