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02 Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of California 11 - 1176782 <br /> CalRecycle 181(Rev. (Ca[ Survey Form - Rage 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- l Inspection Type(Fill one) <br /> 0 <br /> Site Suffix: tI 5 0 8 :9 0 ( 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local i \ _ If Referral,choose referral type(Fill one) <br /> Identifier: Gr"V-\- v� `�,` C'���i�` �'j 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 1 Inspected By Inspector <br /> red Cx l•�a}m L i✓Ml¢c�,z; <br /> Physical Address c( - L 0 C <br /> Q � <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title © AM ®AM <br /> �" -� `Um �� Sn �� ✓ 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 /> If Active 0 PasAstgng_er 0 Generator 0 Outdoor <br /> ..- /`4 1 IN <br /> O 0 Closed 0 Altered //s{GG /4 <br /> GpS Latitude 0 Hauler 0 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 (8 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 S Other 6'rb�jy� �✓ <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 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 0 / 0 <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) N <br /> 's <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> LU <br /> W <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities - <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 /> ce <br /> Inspection Form Included: <br /> Comments Included: <br /> u s Rep's Signature Phone Number ns a r' atun: Phone Number <br /> INSTRUCTIONS ONMI Incorrect: �j EJ.�ifAk#j L E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LFA, ® 0 <br />