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Waste Tire _:;)urveY 8c ns eotion rte rt*Inspection Report Number <br /> CalRecycle State of California _ 11 - 1245381 <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- i / Inspection Type(Fill one) <br /> Site Suffix: 3 C/ &I 0 > v <br /> • Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �(R (r� � (�j►� � y� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 1 <br /> Physical Address <br /> C''� �S 33�° Inspection Date <br /> 4,p-cc, <br /> Time In Time Out <br /> Business Rep TitleO AM 3 AM <br /> : '5- 'S nZ V W 1 ( �� yvi,5ri/a SPM PM <br /> ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count It le/PTE) '1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> "[ • Active Q Passenger 0 Generator • Outdoor <br /> o Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 41 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 /> Q Notice Of Violation Q Extension <br /> Q Q <br /> 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 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 In Compliance No Violations o <br /> Q Q Other:§ <br /> Comments <br /> lea_ <br /> /JO <br /> Inspection Form Included: Q <br /> Comments Included: ® ' <br /> Business Rep's Signature one Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect: JEjXjA1m_ PjLjEj 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />