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Waste Tire Su. ve & Inspection Re orJOlnspection Report Number <br /> CalRecycle y p p - 1242295 <br /> state of California I 1 <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- 5 _ q Inspection Type(Fill one) <br /> Site Suffix: V I' Routine Q Re-inspection Q Referral Q Observation <br /> Local C c--' If Referral,choose referral type(Fill one) <br /> Identifier: Ctrl JOM41 11,111An 6_9A l,n Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business <br /> 1or Facility Name Inspected By Inspector <br /> Physical Address CS CO TTb <br /> J C A 1 SZD S Inspection Date Qrk / 1 q / i u <br /> O�' D r Time In Time Out J <br /> Business Rep Title 0 AM 0 AM <br /> � � PM � 00 ® PM <br /> CnA[k. <br /> (?-.,t,In V';c- P1es;���' /� <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) a v (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> B Active ® Passenger ® Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> D Q Inactive • Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <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 S Other Ev lln"nl <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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / m <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 /> a <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Lu <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 o <br /> Q Q Other:§ A <br /> Comments ]� J 1 ri <br /> 1. ,� .PJ4y��i1L 0^ A i"1y, <br /> ---ol OIA3n W IA5 n -IJ = <br /> Inspection Form Included: Q <br /> JL <br /> Comments Included: ® <br /> Business Rep's Signature Phone Number Ins a tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:6 Incorrect: g EXAM P L E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop .LE ® 0 <br />