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Waste Tire S ey & Inspection RepoPinspection Report Number <br /> CalRecycle State of California I 1 - 1245330 <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- Z `J _ / Inspection Type(Fill one) <br /> Site Suffix: V `-C I ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Sow) SOG t.� &u- 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name C/�'� Inspected By Inspector <br /> :�C- f o mcg ►� 2DCi - l <br /> Physical Address <br /> C �� Inspection Date 7 <br /> P� - <br /> � <br /> Time In Time Out <br /> Business Rep Title z / C O AM 0 AM <br /> 5'Tho Ju, I S 0 PM �' ''l QPM <br /> // Operational Status Tire Type Business Role Storage Type <br /> G�Tire Count 6h le/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count h le/PTE) <br /> (6 Active S Passenger • Generator 0 Outdoor <br /> GPS Latitude O 0 Closed 0 Altered 0 Hauler 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 /> • New Tire Dealer • Auto Repair 0 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 0 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 /> 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 <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXn N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 2 <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 S In Compliance-No Violations <br /> 0 0 Other:§ <br /> Comments <br /> U Au, 1 Ak)� c� r . <br /> Inspection Form Included: Aid <br /> " J <br /> 1;2b9 07W 12V <br /> Comments Include <br /> Business Rep's Signature Phone Number nspector's re Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorre=X �� E X A M P L E 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />