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E 0 Waste Tire Survey & Inspection Report <br />cal Recycle State of California <br />CalRecycle 181 (Rev. (Ca[ Survey Fora - Page 1 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />Part A - Survey <br />Inspection Report Number ■ <br />11 -11.76795 <br />BLUE OR BLACK INK PEN <br />Business Profile <br />Operational Status Tire Type Business o e forage <br />Inspection Details <br />(Fill all that apply) <br />(Fill all that apply) <br />TPID -Inspection Q I r7(] � _ <br />Site Suffix: �Q 1 <br />Inspection Type (Fill one) <br />Q Active <br />Q Closed <br />0 Passenger <br />Q Altered <br />®Generator <br />Q Hauler <br />Q Routine Q Re -inspection <br />Q Referral <br />Q Observation <br />Local ^� <br />Identifier: ) 6( n (OL1i{1 <br />If Referral, choose referral type (Fill one) <br />Q CHP Q CalRecycle Q Complaint Q Educational <br />Visit Q Other <br />Business or Facility Name <br />50"Wo_5 <br />Inspected By <br />Inspector <br />Q Planned <br />Physical Address <br />q -1 a I <br />Ren <br />Es of o <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader <br />Q Dismantler Q Tire Derived Fuel <br />Q Used Tire Dealer Q Auto Body Q Car Dealer j Q Collection Q Crumb Rubber <br />S� �� �SaoS <br />Inspection Date <br />Part <br />4 <br />O�� <br />Time In <br />Time Out <br />_V]_AJ <br />Business Rep Title <br />I C 0 AM <br />J <br />0 AM <br />Jtsy� AkV(A(uaa 01A)rV-r <br />® PM <br />® PM <br />Q Notice Of Violation Q Extension <br />R I S T <br />`SCS, Co:!,n �l <br />Inspection Form Included: Q <br />�j ��, . ( <br />Comments Included:eSgna <br />ture P'usinsRe'hAe Number <br />INSTRUCTIONS ON BACK [Correct: 0 Incorrect: <br />■ White Copy: CalRecycle Yellow Copy: Operator <br />Pink <br />-Phone Number <br />62081 <br />—&A ■ <br />Lu <br />W <br />one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />ype <br />(Fill all that apply) <br />Tire C011nt (Whole/PTE) (D(Fill <br />Q Active <br />Q Closed <br />0 Passenger <br />Q Altered <br />®Generator <br />Q Hauler <br />Q Outdoor <br />®Indoor <br />O <br />CaP� Latitude <br />Q Inactive <br />Q Truck <br />O <br />Longitude - <br />Q Planned <br />Q OTR <br />Q End -Use <br />Q Container <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader <br />Q Dismantler Q Tire Derived Fuel <br />Q Used Tire Dealer Q Auto Body Q Car Dealer j Q Collection Q Crumb Rubber <br />Q Service Station Q Hauler Q Agriculture Q Shredder ® Other <br />LA)ir) (41 f <br />Part <br />B - <br />Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />ENFORCEMENT STATUS <br />_V]_AJ <br />HAULING AND MANIFEST REQUIREMENTS <br />Q Notice Of Violation Q Extension <br />Q <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Compliance Deadline <br />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Date m / Ffl/ m <br />Q <br />0 <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />Q <br />Q <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />(Required for NOV or EJCT) <br />Q <br />Q <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q <br />Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q Referred / CalRecycle Enforcement <br />Q <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />O <br />0 <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />® In Compliance - No Violations <br />Q <br />Q <br />1 Other: § <br />Comments <br />Qr�.\VAP_ <br />`SCS, Co:!,n �l <br />Inspection Form Included: Q <br />�j ��, . ( <br />Comments Included:eSgna <br />ture P'usinsRe'hAe Number <br />INSTRUCTIONS ON BACK [Correct: 0 Incorrect: <br />■ White Copy: CalRecycle Yellow Copy: Operator <br />Pink <br />-Phone Number <br />62081 <br />—&A ■ <br />Lu <br />W <br />