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Waste Tire Su. vey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California 11 - 1196446 <br /> CalRecycle 181(Rey.10/10) <br /> 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- 22 Inspection Type(Fill one) <br /> Site Suffix: ` 3 J S q ( 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local //� If Referral,choose referral type(Fill one) <br /> Identifier: SooV'A Jcc_Ct Av\ �FJ</1't/ � 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Bus`'iness or Facility Name Inspected By Inspector <br /> 1 e VARcc) Camjoa q �. <br /> Physical Address 7J - 1 O p�A-V-1(S <br /> Inspection Date / / - / 13 <br /> Time In Time Out <br /> Business Rep Title ®AM (0 AM <br /> / <br /> ( C I S O PM � p � � 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 /> 0 Active 0 Passenger ® Generator • Outdoor <br /> - o <br /> G PS Latitude 0 Closed 0 Altered <br /> 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of Violation Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance No Violations o <br /> 0 1 0 1 Other:§ <br /> Comments <br /> Inspection Form Included: 0 <br /> Comments Included: <br /> Business Rep's Signature Phone Number Ins ctor) Ignature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: EXAMPLE 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />