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Waste Tire Survey & Inspection Report Inspection Report Number <br />CalRecycle State of California I 1 m 1242111 <br />CalRecycle 181 (Rev. (CalRecycle)Survey <br />Survey Form - Page 1 <br />Dept of Resources Recycling and Recovery(CalRecycle) <br />D�.4 e - c..m.a.. BLUE OR BLACK INK PEN <br />Business Profile <br />V <br />A <br />Inspection Details <br />Q <br />TPID -Inspection <br />u <br />Site Suffix: C �, T 4 <br />1 41 <br />Q l <br />Type (Fill one) <br />Q Routine ® Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br />Local <br />Identifier: �a Vl .xJ�Ln G-� <br />Business or Facility Name <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />Inspected By Inspector <br />Q <br />Physical Address (i <br />Q <br />Q <br />� <br />C� <br />MIS c Z-4 <br />8115" c . Ciut,• i <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <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 />CA <br />a5aVol� <br />Inspection Date <br />Q <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />n <br />Time In <br />Time Out <br />Business Rep <br />.�, <br />Title <br />GQr12fG _ <br />O AM <br />L Z ' D kS ® PM <br />7 C O AM <br />I J ® PM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Tire Count (Whole/PTE) <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />V <br />® Active <br />Q Closed <br />® Passenger <br />Q Altered <br />a Generator <br />Q Hauler <br />le Outdoor <br />Q Indoor__ <br />O <br />��� Latitude <br />O <br />Q Inactive <br />Q Truck <br />Longitude - <br />Q Planned <br />Q OTR <br />O End -Use <br />Q Container <br />Business Type (Fill all that apply) <br />® New Tire Dealer 0 Auto Repair <br />Q Trucking Fleet <br />Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br />Q Used Tire Dealer Q Auto Body <br />Q Car Dealer <br />Q Collection Q Crumb Rubber <br />Q Service Station Q Hauler <br />Q Agriculture <br />Q Shredder Q Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V <br />A <br />HAULING AND MANIFEST REQUIREMENTS <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 />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 />Q <br />Q <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 />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 <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />n <br />n <br />Other: § <br />Comments <br />Inspection Form Included: <br />Comments Included: <br />® INSTRUCTIONS O <br />-f q Y�d(le0 <br />ep's ignature Phone Number I <br />Correct: Incorrect: M 4 I C l <br />White Copy: CalRecycle Yellow Copy: Operator Pink <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EXT) <br />Q Referred / CalRecycle Enforcement <br />In Compliance - No Violations <br />!-166-767S <br />Phone Number <br />62081 <br />