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Waste Tire SAey & Inspection Repo spection Report Number <br /> State of California <br /> CalRecycle I 1 - 1242063 <br /> CalRecycle 181(Rev.y(Cal 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- Inspection Inspection Type(Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local \ / If Referral,choose referral type(Fill one) <br /> Identifier: S&Vk- JOGL6. \ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> ��� _&y\ OV;.AX16 .%C1k«0( +0 1&_kvl� 3 <br /> Physical Address - 1 D It lqf It -m/e a-4 <br /> 9J%3 A_flllVt� v_V JJj Z.►1 <br /> ��L��'�y� !� pInspection Date 4 / 0 -5 / t L <br /> - '� ` Time In C) Time Out <br /> Business RepAM j L� $AM <br /> .' <br /> 'W�Gvtic� ' D O PM l L O O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) C' (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> T ® Active Q Passenger e Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned ® OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet ®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 /> 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 EXT) N <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 <br /> In Compliance-No Violations o <br /> Q 1 Q 1 Other:§ <br /> Comments <br /> Inspection Form Included: Q X� <br /> Comments Included: 4P /j D •Y <br /> Business Rep's Signat re Phone Number In pe or's Aig4ture Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: 7x*-V—1 E I X I A M 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co y:L <br />