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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> cal Recycle State of California 1 1 - 1176771 <br /> CalRecycle 181(Rev. (Cal Survey Form - Page 1 <br /> Dept,of Resources Recycling and Recovery(CalRecycle) <br /> Sart A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- y � �'l � I _ � /� _ O I Inspection Type(Fill one) <br /> Site Suffix: ) I l,Q 1S Q Routine 0 Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: S�n (k �� n (�� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Q��1� � (w� A ��c.s5or1 i cs - I o �Z <br /> Physical Address -3 1 PJ Z,AD <br /> � Inspection Date I / I � / ` 1 <br /> �' � Sd Time In Time Out 1 <br /> Business Rep Title 0 AM 0 AM <br /> • PM v ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> ' 0 Active Passenger Generator ® Outdoor <br /> O Q Closed Q Altered ' <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS '�1 <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q ° <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> ° Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> ° Q PRC§42956-Registration/Decal in Vehicle <br /> Q ° 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> ° 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 o <br /> Q ° 14 CCR§18460.2- Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Lu <br /> W <br /> ° 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:§ <br /> Comments k,vl <br /> Av O-os V WaJAS �vl (ktr_1, J f�jej I <br /> Inspection Form Included: �Z_ <br /> p °I , may, 3� rPL <br /> 3-78 <br /> Comments Included: Q i s Rep's Signature P one Number Insp re Phone Number <br /> 62081 <br /> INSTRUCTIONS OfACK Correct:* Incorrect: E X A �'1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co y:L ■ <br />