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Waste Tire Survey & Inspection Report Inspection Report Number <br /> dal Recycle State of California I 1 - 1176431 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <br /> Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-_Survey - - _ BLUE OR BLACK INK REN <br /> ,iness Profile Inspection Details <br /> ID_ S Z Inspection Type(Fill one) <br /> Site Suffix: s .2 Q ' ® Routine O Re-inspection O Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: �'J""_--- J1ry Q CHP O CalRecycle Q Complaint Q Educational Visit O Other <br /> Business or Facility Name /1 <br /> Inspected By Inspector <br /> to_Qta e "\ <br /> Physica Address <br /> 3� y i41 L9 L - <br /> Inspection Date CD / ) 3 / r / <br /> Time In Time Out <br /> Business Rep Title r U O 0 AM I U r 0 AM <br /> ® PM t T QPM <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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> ® Closed Q Altered <br /> P� Latitude — --_ Q Hauler -4ndoor- <br /> 0 Q Inactive p Truck <br /> Longitude - O Planned Q OTR 0 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 O Tire Derived Fuel <br /> Jsed 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 O Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> PRC 42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q § 9 � Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> OO 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> (Required for NOV or EXE <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> N <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years i <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CalRecycle Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations <br /> Other: <br /> Comments <br /> '9A.,f L,i 11__ ;n c{xe fm`c'- -:?R e r ::Zf tg- a4,,j 7Zz"- 2l�rr c�ywt <br /> lA_A C t40 4=_ = - <br /> ection Form Included: O <br /> Comments Included: - - [ ��,�L16 -cD623 <br /> Business Rep's Sure Phone Number Ins�Signature Phone Number <br /> INSTRUCTIONS ON BACK Incorrect 62081 <br /> �Correct: ` E X A P L 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink CA- <br />