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Waste Tire St*ey & Inspection Report nspection Report Number <br /> cal Recycle State of California I 1 - 1176570 <br /> CalRecycle 181(Rev. (Ca[ 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- Inspection Type(Fill one) <br /> Site Suffix: ) ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SG�.1-„' `�'�' Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name----' n/ Inspected By Inspector <br /> tl ckd rz f - ! O <br /> Physical Address ✓✓ <br /> 3 yo 3 Ma r� Sf <br /> Inspection Date 0 ,9 <br /> Time In Time Out <br /> Business Rep Title 0 AM _ 0 AM <br /> 0 _S ' d 0 P ® 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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> ® Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q 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 Q 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 /> . _ . .......---- -— - ---._ .. --- -- - <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 N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <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 /> 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 Q1 Other:§ <br /> Comments <br /> A-IA;Nn5l �/7(�C.�icase <br /> Inspection Form Included: Q 00, <br /> Comments Included: ® ' 6o' ©� 3 <br /> Business Rep's Signature Phone Number "Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: ( � EXAM L 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop L <br />