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Waste Tire SG. .fey & Inspection Report inspection Report Number <br /> State of California <br /> CalRecycle I 1 ® 1177798 <br /> CalRecycle 181(Rev. (cal Survey Form - Page <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 Type(Fill one) <br /> Site Suffix: ' 4 1 -2, '7 '-1 ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �� � �� �� If Referral,choose referral type(Fill one) <br /> Identifier: -'Cil 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 39 f c, f <br /> /101(0 El <br /> �-y ^ Inspection Date <br /> t 0 Time In ` Time Out I <br /> Business Rep Titlei ' TT V 0 AM 0 AM <br /> l Z '9 0P Z 0P <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � � <br /> ® Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> 0 Notice Of Violation 0 Extension <br /> 0 0 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 2 <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments <br /> See- 6--i►LV12zNl/�3 �� N <br /> Inspection Form Included: 0 / <br /> Comments Included: <br /> Business Rep's S' ure Phone Number Jo6pegeorls Sigfiatytte Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E X A E 11213 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink C y ® ■ <br />