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Waste Tire Suis vey & lnspec'�Lion Report Inspection Report Number ■ <br /> CalRecycle State of California I l e 1242361 <br /> CalRecycle 181(Rev.y(CalRecycle) Survey <br /> S I]f;vey For/'�}� o Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) �1� V lcs ��rf <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- C Inspection Type(Fill one) <br /> Site Suffix: �j 3 © p ' o 1 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: � �ur1 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Addfess -) Q 1 `} <br /> X00 W• a.\Q,ez' cA S t ' <br /> 5376 Inspection Date O 2- <br /> Tia U1 Time In Time Out 1 <br /> Business Rep Title AM *AM <br /> 1 TCtunS�e�O `��01/) 1 0 - 1 5 Q PM Q S 0 PM <br /> -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) �( (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> !(/—� 40 Active Q Passenger 9 Generator Q tQA <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive 0 Truck <br /> Longitude - Q Planned 0 OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) \-O <br /> Q New Tire Dealer Q Auto Repair 0 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 Wo,ll�cy�ctT����5 '�4t�Z�4I� <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 Q § - --- -- Q Notice Of Violation Q Extension <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 /> 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 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 /> 2 <br /> Lu <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators *In Compliance-No Violations <br /> Q 1 Q 1 Other:§ <br /> Comments <br /> o > o eM <br /> Inspection Form Included: Q 00- `2CA <br /> Comments Included: ® �_04 <br /> Business Rep's S' natu one Number Insp tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:4D Incorrect: E X A M P L E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />