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M Waste Tire S`vey & Inspection Repor Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 1176564 <br /> CalRecycle 181(Rev. (CalRecycle) <br /> 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- Inspection Type(Fill one) <br /> Site Suffix: ' 3 o 6 0 r <br /> ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �tyin --jpry�; Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name---/ G// Inspected By Inspector <br /> /J;.// �lc sn1'� 1 A� <br /> Physical Address .3 <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title ® AM A AM <br /> 0 Q PM 2 S Q PM <br /> �e me-4- Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) C A O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' 7 ® Active ® Passenger ® Generator ® Outdoor <br /> o Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck. <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer ® 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 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 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 pate m / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> n <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ W <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations �o <br /> Q Q Other:§ <br /> Comments \u <br /> -- - ell.cfiict< <Ctcf�tc cam- 1 r112 G G � <br /> Tll c A0;g g t t n c>kad <br /> Inspection Form Included: Q <br /> Comments Included: «�/J i'6X—06 23 <br /> eep4S, a Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct'1, Incorrect: X E X I A I M L 1112131 <br /> 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy LEV <br />