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Waste Tire Sw dey & InspecVon Report nspection Report Number <br /> CalRecycle State of California 11 — f� f y ({ 2 1 3 <br /> CalRecycle 181(Rev.y(Cal Survey Fora ® Page I e (� e <br /> Dept.of Resources Recycling and Recovery(CalRecycle) _ gLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details - <br /> TPID- r G l ' �7 n Inspection Type(Fill one) <br /> Site Suffix: /1 q J '1 —1 © ' 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �GQ9 V CO%3 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Bu <br /> si <br /> ness or Facility Name Inspected By Inspector <br /> Physical Address 3 <br /> �53?6 Inspection Date <br /> Y7 Time In (� Time Out <br /> Business Rep 1 Title 5 ® AM 1' 1S AM <br /> 1 0 S QPM � `' � S QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) ( r� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' / 0 Active 0 Passenger # Generator . Outdoor <br /> D 0 Closed 0 Altered <br /> G�� Latitude Q Hauler ® Indoor <br /> 0 0 Inactive ® 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 Trucking Fleet 0 Government 0 Retreader 0 Dismantler O 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 /> �Notice Of Violation 0 Extension <br /> O O <br /> 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 /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m <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 EXE <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators .In Compliance-No Violations o <br /> 0 1 Q Other:§ <br /> Comments 9n&1`�Ill l�U S4e� � 'QZV`S ��C��4 &YN2. (�Iy6 <br /> �����d�� <br /> Inspection Form Included: 0 <br /> Comments Included: Ze �4bg�3 <br /> siness Rep's S nature Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: EXAMPLE 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />