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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California 11 -1176747 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <br /> 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- f t ( ' 1 Inspection Type(Fill one) <br /> `' <br /> Site Suffix: I "� L I <br /> 0 Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: S GI{� J CO 0 CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name b <br /> Inspected By Inspector <br /> N`i 46en ( � e,) neTr 3 9 - I U �l <br /> Physical Address Irj <br /> IV'_7 W . ` se rn t� - Ave-- <br /> rn u� Inspection Date ' O / 04c,w, C,A 9 5 331 v lJ L J <br /> Time In Time Out <br /> Business Rep TitleO AM O AM <br /> ' I O 0 PM U 0 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 /> Active Q Passenger • Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> 0 Q Inactive • Truck <br /> Longitude - Q Planned Q OTR O End-Use ® Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q 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 /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires — Notice Of Violation Q Extension <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q ® 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXTJ N <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ __ ___ w <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q O Other:§ <br /> Comments R-o4 cv- A\3 c t n51"nn C _ne oA)^ <br /> S A�Ah of <br /> L-113 as n CL "A <br /> �, F <br /> Inspection Form Included: 0 <br /> Comments Included: ®- — ------ ----- - �— <br /> _ B sin s Rep's Signature Phone Number Insp or's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS O ACK Correct:0 Incorrect: l E X A M L E 1112 n3 <br /> 0 White Copy:CalRecycle Yellow Copy:Operator Pink Co y, © ■ <br />