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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1230330 <br /> CalRecycle 181(Rev. (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- c <br /> � c � � � - Q � Inspection Type(Fill one) <br /> Site Suffix: a Routine Q Re-inspection Q Referral Q Observation <br /> Local < / If Referral,choose referral type(Fill one) <br /> Identifier: J�1(\ -jD(�Ci t�(j/1 t t7�(1 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name I Inspected By Inspector <br /> b utie_ rrc - Ti rc s ?� 5 - 0 <br /> Physical Address oeg t n TTO <br /> Inspection Date 3 / G / 1 '5 <br /> OL 5Lbs Q VJ 1 <br /> Time In Time Out <br /> Business Rep c Titles ` D U O AMG `� O AM <br /> Z�,1,n 1 � 1�2�� �+ 1� 1�-t-Y1 (,n�L � PM J �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 /> {,�r�� <br /> ' ' V ® Active it Passenger ® Generator a Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude 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 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 EX7) 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 /> 1010 Other:§ <br /> Comments ")5 `t At, <br /> 64,nki� <br /> '\/170" 61 ctrl - <br /> Inspection Form Included: Q " 1 M R()G&' - -.A)(W9 <br /> Comments Included: —�� )Ca <br /> Business Rep's Signature Phone Number Insp or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: EJXJAJ I 11213 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop :LE ® 0 <br />