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Waste Tire Survey & Inspection Repon Inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1242480 <br /> CalRecycle 181(Rev.y(CalRecycle) Survey <br /> Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-SurveyBLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 r,� q q 3 j Inspection Type(Fill one) <br /> Site Suffix: ` d c}�� 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local �- ( If Referral,choose referral type(Fill one) <br /> Identifier: S(,L n J O" Lbs n C(�U� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name o <br /> Inspected By Inspector <br /> (•CJI.c <br /> Physical Address <br /> Inspection Date <br /> c CACt J l/S3�ti( Time In Time Out0 <br /> Business Rep Title 0 AM 0 AM <br /> ® PM ® PM <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) a (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> • Active ® Passenger ® Generator ® 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 /> Q Used Tire Dealer Q Auto Body ® 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 / 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 EXE N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <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 /> nL t <br /> Comments 1Wall'At I A)U5AC,_�tfc- )� �iL�lu1 uW'1f U'1�1ti.S au,��, �J11�1V\ f UU 7� <br /> k &)eAS 10n .l '_ <br /> �1 0 Vi0� S v3 ��,1ei o� G�11CQr� <br /> Inspection Form Included: <br /> Comments Included: ® / (do/J ��� q?go <br /> Ne <br /> une <br /> siss Rep's Sigrill Phone Number Insp or's Signature Phone Number <br /> __4�INSTRUCTIONS ON BACK Correct: Incorrect: X NJ EXAM L 11213162081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy L <br />