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Waste Tire Su. vey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CalRecycle 11 - 1242369 <br /> CalRecycle 181(Rev. (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- , ® Inspection Type(Fill one) <br /> Site Suffix: a jS ® Routine Q Re-inspection Q Referral Q Observation <br /> Local �+ If Referral,choose referral type(Fill one) <br /> Identifier: To qL j'\Ar ' /.�U� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name www Inspected By Inspector <br /> �O,f' Dov -S G���, 0 - fol v <br /> Physical Adl�Fess AA <br /> S W'� �c <br /> SC_\A0y-\ - <br /> Inspection Date 0 z / 1 � / I <br /> C� °15215 <br /> Time In Time Out <br /> Business Rep Titler � � 0 AM � ®AM <br /> t ® <br /> � 1, 0 PM � � PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 2 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> .7 1* Active ® 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 - Q Planned Q OTR ! End-Use ! Container <br /> Business Type(Fill all that apply) <br /> 0 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 /> 40 Notice Of Violation Q Extension <br /> Q Q <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 49 Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Datemv-3 <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle M14 N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7J N <br /> a <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 Q In Compliance-No Violations o <br /> 0_L0_ <br /> Other;§ ` <br /> Comments �y eL�OY` N,.t� c c>\6" �` \C. <br /> Inspection Form Included: <br /> Comments Included: Isl� I <br /> Busi s Rep's S ature Dh"4 Number Inspec or's Signature Phone Number <br /> INSTRUCTIONS ON BAC �Correct:0 Incorrect: jEjXjAjM� PjLjEj 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />