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Waste Tire vey & Inspection Report 'Inspection Report Number <br /> CalRecycle State of California I 1 - 1230104 <br /> CalRecycle 181(Rev. (Ca), 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- `� O / q (� I 1 - 0 I Inspection Type(Fill one) <br /> Site Suffix: ` ` "� Q Routine -' Re-inspection Q Referral Q Observation <br /> LocalC� t ] If Referral,choose referral type(Fill one) <br /> Identifier: Al n 44 J1 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> � Inspected By Inspector <br /> F ee _�j rc_ tic., q _ I '^ <br /> Physical Address o <br /> 3 1 ` <br /> 3��b <br /> �O I✓rl.�l U''� 9SZos Inspection Date �1 � 1 5 � � S <br /> Time In ` Time Out <br /> Business Rep Title ('� O AM O AM <br /> � n 1 `' ® PM ® PM <br /> Jery�� `7r��u�• (��r1e!' <br /> -- --- Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) a 3 t79 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active ® Passenger ® Generator • Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude ® Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned ® OTR ® End-Use ® Container <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government 6 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 ® 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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or E?C7) N <br /> r <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 Q 1 Other:§ <br /> Comments "0+�1_�jlv1 <br /> Inspection Form Included: <br /> Comments Included: Q <br /> Busine s ep's Signature Phone Number Ins tor's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: � Ve g EXAM L 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy. <br /> L <br />