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Waste Tire S6, vey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1177643 <br /> CalRecycle 181(Rev. (Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> 'art A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: ' 6 C1 J L-( - j ® Routine Q Re-inspection O Referral Q Observation <br /> Local ( If Referral,choose referral type(Fill one) <br /> Identifier: ��� � �v� Lc; / O CHP O CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name /// Inspected By Inspector <br /> Physical Address <br /> Inspection Date <br /> Lv,.Ntic <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> Q rr./hZr�s __)' ' -]� U�7 ® PM 3, C� ® PM <br /> Eo-c- 6-mf41 <br /> L —1' Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active O Passenger 4§ Generator ® Outdoor <br /> Q Closed O Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> 0 Q Inactive ® Truck <br /> Longitude - O Planned O OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <br /> O New Tire Dealer Q Auto Repair ® 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 ® 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 Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle � <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXIT <br /> a <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> O 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 /> 0 O Other:§ <br /> Comments <br /> v <br /> Inspection Form Included: O <br /> Comments Included: ® Z�9 Qz° ° 71 .9o'3Pho e Number <br /> usiness s Sl re Phone Number InVr'sSig6&UP6 Phone Number <br /> INSTRUCTIONS OAC Correct:0 Incorrect: � E XI 1 (2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator �� ■ <br />