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Waste Tire'Su. ve & Inspection Re o*Inspection Resort Number <br /> CalRecycle State of California Y — ■ <br /> Y CalRecycle 181(Rev.y(Cal Survey Form - Page 1 I 1 1210454 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 1 Inspection Type(Fill one) <br /> Site Suffix: e u �p -� Q ® Routine Q Re-inspection Q Referral Q Observation <br /> Local f If Referral,choose referral type(Fill one) <br /> Identifier: S&Y) �2A1f�/�)n C17un Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name LL Inspected By Inspector <br /> gci <br /> Physical Address 3 l l b <br /> a -lob r�ssb� <br /> TrUInspection Date / U / 1 <br /> �vJ e A ��37 <br /> Time In Time Out <br /> Business Rep /� l_ Title l 1 2 T ® AM Q O AM <br /> <, U l7 " 4 �)' I J V 0 PM i PM <br /> 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 ® Passenger 0 Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Truck <br /> Longitude — Q Planned ® OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet a 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 ® 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 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 EXT) 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 w <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 /> n§ <br /> Comments &c'Aq'ru n5j�(�{ 1� lU(Tr� D-1)_ <br /> 141. 1i IL wI►�0 'n <br /> )o v H c LAI i tvI3 o) Ca)cui S 4 w.A o m- <br /> Inspection Form Included: <br /> Comments Included: * *,,eRp, <br /> u Signature Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: ( ( E X 62081 <br /> A I E I 11 2 1 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink CZ <br /> �� 0 <br />