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Waste Tire Su. Bey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 1196663 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <br /> 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- 1, �j Inspection Type(Fill one) <br /> Site Suffix: I -` 7 �j C> y -I © 1 46 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SQ,.\ ao„A V Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name `^"� f <br /> Inspected By Inspector <br /> Physical Address M K� v <br /> loo <br /> S <br /> C� 9S2o3 Inspection Date 1 -Z 6 J 1 3 cti�o.n <br /> Time In Time Out <br /> Business Rep Title c 0 AM 0 AM <br /> OQefa_hov\.S I 5 PM 2 3 5 PM <br /> C a <br /> Mc_ � 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 /> 0 Active Q Passenger 10 Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 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 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 <br /> 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 /> N <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 /> a <br /> Q Q 14 CCR§18459.3 Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Lu <br /> Q 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 <br /> Inspection Form Included: Q _ .,�'"�G�" � �I"Q��✓r �%//4�/ !�"' li F U"����� <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: � � NJ E X A M P L l E ( 1 (213 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ■ <br />