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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 1176432 <br /> CalRecycle 181cover (Cal Survey Form - Page 1 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I Inspection Type(Fill one) <br /> Site Suffix: 5L2 <br /> S 4 0 Routine Q Re-inspection 0 Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. �,� t_ may` O CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name) --�-; Inspected By Inspector <br /> I Dry Lv.,,-d—�„tal <br /> Physical Address 1 0 <br /> Street <br /> Inspection Date <br /> L-- -ccAC+cit, CA q sztS <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title6FLI <br /> 1 0 AM / FY <br /> a 0 AM <br /> 0 PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> � I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) 1L]r I �_ +L__ 1. __�_Y j 9 0 <br /> �-�— Active Passenger Generator 0 Outdoor <br /> GPS Latitude Om• ® Closed O Altered <br /> Q Hauler Q Indoor <br /> 0 O Inactive O Truck <br /> Longitude - O Planned Q OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer O 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 /> VIA I HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / / m N <br /> Q 0 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 E1C7) A <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred"/.CalRecycle Enforcement'.'- <br /> 0 <br /> nforcement.O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations10 1 o <br /> 0 Other:§ I I <br /> Comments C,9 <br /> JG" <br /> 9cJGc.n /20/�'c1O <br /> Inspection Form Included: Q <br /> FComments Included: ® Business Rep's Signature Phone Number 1 ector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correc .* ncorr : � 62081 <br /> �t I E X I A M P I L E 1, 2 3 <br /> ■ White Copy:tec Yellow Copy:Operator Pink Copy:LEA ®' ■ <br /> I_ <br />