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03' Waste Tire S#ey & Inspection Reporp Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1255983 <br /> ry <br /> CalRecycle 181(Rev. (Ca(CalRSurvey Form - Page 1 <br /> Dept.of Resources Recycling and Recoveecycle) <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � � � � � 1 _ � t Inspection Type(Fill one) <br /> Site Suffix: * Routine O Re-inspection O Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �S�'^ O CHP Q CalRecycle O Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address `" 3 - 1 d ' MA <br /> -V'V <br /> C� Inspection Date <br /> Time In Time Out <br /> Business Rep Title I 6 AM 1 *AM <br /> QPM F � O � QPM <br /> r �� O W V� Operational Status Tire Type Business Role Storage Type <br /> „[ (Fill ne o I (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) /(U <br /> A v Q Passenger Q Generator Q Outdoor <br /> O 0 Closed O Alterecy/� N IA- N 1/� <br /> GPS Latitude N A- Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - O Planned O OTR O 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 /> 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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O 0 PRC§42956-Registration/Decal in Vehicle <br /> I00 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) cm <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> O 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 Q Other:§ <br /> Comments, Zhs Wks. \ <br /> K)6 V O��v�S <br /> l 7 51--CA 6Z_ UosNew 61S;AKS -'s ` <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspe is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E X I A M P I L E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />