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Waste Tire Su. ,iey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California 11 - 1210334 <br /> CalRecycle 181(Rev.y(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- O O , Inspection Type(Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local . . If Referral,choose referral type(Fill one) <br /> Identifier. SG.v- J O V;r CO O CHP Q CalRecycle Q Complaint O Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Aress �j `► - 1 \ �1 <br /> Inspection Date <br /> �tc�k�ov� C �S2 I S <br /> Time In Time Out <br /> Business Rep T�iitle *AM Q AM <br /> � QPM � � � O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) -7 Q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' / L7 . Active 0 Passenger 0 Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - O Planned Q OTR O End-Use Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 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 0 Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> QQ 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) N <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CalRecycle Enforcement � <br /> O Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators IS In Compliance-No Violations o <br /> Q 1 0 1 Other:§ - <br /> -- z <br /> Comments <br /> fie_ nkl ossaA- VNCP kms'• <br /> Inspection Form Included: 4 <br /> 1AJV_Comments Included: <br /> usiness Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK [Correct:0 incorrect: X 4_V7 IEIXIAIMIPILIEI 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />