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Waste Tire Survey & Inspection ReporX Inspection Report dumber <br /> CalRecycle State of California I 1 - 1230211 <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�J Inspection Type(Fill one) <br /> Site Suffix: ' 5 l -I / 3 O 1 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local n If Referral,choose referral type(Fill one) <br /> Identifier: 65�Q �ky �v� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name T� Inspected By Inspector <br /> York\ ���, 9 _ 1 0 T v <br /> Physical Address <br /> 766o I O 2wc_cx c <br /> Inspection Date / C> / <br /> Time In Time Out <br /> Business Rep Title q * AM �\ !�AM <br /> n 1 Q PM � ' �J 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) T� b (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active • Passenger 0 Generator 0 Outdoor?6 <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 10 Truck <br /> Longitude - Q Planned Q OTR Q End-Use ® Container3 <br /> Business Type(Fill all that apply) <br /> Q 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 Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 0 Other PC;Soh <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXTJ <br /> a <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 /> 2 <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 1 Q 1 Other:§ <br /> Comments Qb��r�An2 W CIA& T�VE_ �Y�S P�C �ir1 �y� Bh A)nsk S Ack_.�� <br /> 4110\1c�-� <br /> Inspection Form Included: O <br /> A. /X -32ZIComments Included: - L <br /> usiness Rep's ignature Phone Number Insp tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: � � � IEIXIAIMIPILIEI 111213 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />