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Waste Tire S ey & Inspection Report *Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 121014 4 <br /> CalRecycle 181(Rev.y(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 /> Site - I � �.} 1 �7 - o 1 Inspection Type(Fill one) <br /> Site Suffix: `t'� ` L ` ® Routine � Re-inspection QReferral <br /> Q Observation <br /> Local 5 \ _ If Referral,choose referral type(Fill one) <br /> 0. , <br /> Identifier: o� � � Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> 1 Inspected By Inspector <br /> C- h 0.y,-_2 7_vf�-S;, <br /> Physical Address 3 9 - l 1 MATT- v <br /> ,I Zo s F. M,<oh S� <br /> Sko�Z_vVCD CA gs215 Inspection Date 8 / O to / <br /> Time In Time Out <br /> Business Rep Title � L w � 0 AM ' Q � � 19 AM <br /> � PM <br /> Q 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 (V1/hole/PTE) <br /> Active • Passenger 0 Generator 0 Outdoor <br /> GPS Latitude Ci Closed Q Altered Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> • New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <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 EX7 N <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 &n Compliance-No Violations o <br /> Q Q Other:§ <br /> Commentsz <br /> '�•n.�: �o.�.rc � tea. '' �_ c'1;..aVF ��� o� �n�S <br /> G <br /> rc <br /> Inspection Form Included: Q�r�M CA n�0 �// /�- �j t <br /> Comments Included: I ./ / ' `)" ��IT 20 —�"$' -! <br /> Business Rep's Signature Phone Number Inspect is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: E X A M P L E 1112 3 62081 <br /> Whit y:C ecycle Yellow Copy:Operator Pink Copy:LEA <br />