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OZ Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CalRecycle I 1 - 1210401 <br /> CalRecycle 181(Rev. (Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> P^,t A- Survey BLUE OR BLACK INK PEN <br /> ness Profile Inspection Details <br /> i PID- � � � � � � � - O I Inspection Type(Fill one) <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local � If Referral,choose referral type(Fill one) <br /> Identifier: Sam J(�(,(, �11n (0 u Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> �b /� <br /> �a� C, 3 - 1 1 �sz <br /> Physical Addresss Ca <br /> �1 Q � (�TTV <br /> (-o33 ( 1E . V v a-b cr 1111 lO�J a <br /> Inspection Date � ]� / Q -Z / 1 <br /> O Lv(��Qn CA 9��'S Time In v Time Out <br /> Business Rep Title l c� : 3c 0 AM O 0 AM <br /> J * PM ® 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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> GPS Latitude ° 8 closed Q Alte�d N)� N I0 <br /> Q Hauler Q Indoo <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 D <br /> Q Service Station Q Hauler Q Agriculture Q Shredder A Other P-o,S)tty 62_ <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 M / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle i <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE n <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 /> 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 Q Other:§ <br /> Commentslk 'It- i(1s ip-, r. <br /> N <br /> V [' i S G1 P�(LCG_ �� O Li `T�1 (/� d'tiv-f'ryuu 610A�r1 P (- ''n <br /> �,�cnS�, �si—C j"f� CA.lt9 l II'' csor e. sc TPT�- <br /> ..,pection FormIncluded: Q <br /> Comments Included: Q I - <br /> Business Rep's Signature Phone Number lnsptor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: EXAM E 1112131 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop :L © 0 <br />