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Waste Tire S rve & Inspection Re oftspection Report Number <br /> CalRecycle State of California Y _ ■ <br /> CalRecycle 181(Rev.y(Cal Survey Form - Page 1 I1 1210124 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- "r7 _ Q � Inspection Type(Fill one) <br /> Site Suffix: S Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. SO n J 0 Ct�j jet,I r� r l9�')n Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name l <br /> Inspected By Inspector <br /> C i ( Alpe "CCA, ( V -)C4'r ec �1d1 Q <br /> Physical Adamss -J 0 ES C'OT -a <br /> 02.0vkMare_. �A - <br /> Inspection Date Q / I q / 1 <br /> Time In U Time Out <br /> Business Rep Title O AM O AM <br /> 0 PM 0 PM <br /> 'P,-i n3'C.nf�E�ill" <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) y ) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 9 Active 0 Passenger 41 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> �p� Latitude Q Hauler � Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR Q End-Use ® Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet • 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 N <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 0 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 /> E <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> 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 /> W 1 n ] (,/jt4S <br /> ski to r`CL � T ljJ'm <br /> Inspection Form Included: WBusiness <br /> Comments Included: * C4 <br /> Signature Phone Numb r Insp tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:40 Incorrect: E X A [.11 2.131 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop L ® ■ <br />