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Waste Tire Su,vey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 1229950 <br /> Recycle) <br /> CalRecycle 101(Rev.10/10) Survey Form - Page 1 <br /> Dept of Resources Recycling and Recovery(CalRecycle) Survey <br /> BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: ' V ®' ! > 0 It Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ®actV v� w Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> `CcvGv- SSG <br /> Physical Address MAI <br /> 24;31;s � CV Vk VC�_' <br /> Inspection Date O 2- <br /> Time In Time Out <br /> Business Rep Title ' , ®AM r2 O AM <br /> t 0 PM O PM <br /> ��--- Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) fj ` (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> li I, Active Q Passenger 0 Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 40 Indoor <br /> o Q Inactive Q Truck <br /> Longitude - Q Planned 4j 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 10 Other �. S e(v C�I(�' C-IC <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A I HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation � Extension <br /> Q Q <br /> 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 <br /> Q Q 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 EXE <br /> N <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 /> Lu <br /> W <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> -0 Q Other:§ <br /> Commentsto <br /> ACYr4E <br /> C <br /> M�,-��-i ores Or JN(,R-OLS Co�ce�h <br /> Inspection Form Included: Qkf <br /> O7 Ci �%10V / W� �4—�rJ�/ <br /> Comments Included:. /�' [ J.7 1 (I <br /> ep's gnature Phone Number Insp ctor's Signature Phone Number <br /> INSTRUCTIONS BACK Correct:0 Incorrect: IEIXIAIMIPILIEI 1112F31 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />