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Waste Tire Su. ojey & Inspection Report -Inspection Report Number <br /> CalRecycle State of California I 1 - 1177542 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <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: I 3 2 7 l" q` O I 16 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 1y\ J00lu-, c�� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 43 i v pe't,'ee s JAv�" A'P-.�_�j - <br /> Physical Address -31 - l 0 1 M ATT Q <br /> ►2 �l �, �1h��- 5k. <br /> CPQ °f52 y O Inspection Date (� g I 3 <br /> Ldp,; <br /> Time In Time Out <br /> Business Rep TitleO O O AM O AM <br /> PM 2 PM <br /> �eb6;e� �eevv�e,� �1�2e �2r <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) Z s (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active i Passenger * Generator 4D Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O 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 <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 <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 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 /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities u, <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:§ <br /> Comments <br /> (1 a«kir worms —� c ;ins c c _—C��,tne c�+te t 5 C�CA e <br /> Inspection Form Included: Q I _ Q' <br /> Comments Include : �— ) �A�e <br /> 2ess Reps Ignature Pone Number Insor's Signature Phone Number <br /> I <br /> INSTRUCTIONS ON BACK Correct:• Incorrect: �/ E X AIM P L Ej 111213 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />