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Waste Tire Su. ✓ey & Inspection Report Inspection Report Number <br /> CalRecycle State of cycle 08'1(R I1 - 1242200 <br /> CalRecycle 181(Rev.y(Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-SunT _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- �7 ry O 1 giptin Type(Fill one) <br /> Site Suffix: / "� ne 0 Re-inspection 0 Referral 0 Observation <br /> Local n If Referral,choose referral type(Fill one) <br /> Identifier: ��� J �n N -C-Y'N' GlaV�-y 0 CHP # CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name / Inspected By Inspector <br /> Ca6co'.\ s �� Mo�cS ,� _ O <br /> Physical Address <br /> Inspection Date 0 7 / 2- <br /> Time In Time Out <br /> Busi1ness Rep Title c� O AM 0 AM <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 Passenneer 0 Gen r for 0 OAAutcl or <br /> Latitude O 0 Closed 0 Altered M� N <br /> GPS 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 /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 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 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 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 <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <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 0 Other:§ <br /> Commentso. .v�� 't�C� -��p�L'Ct <br /> ��lzt��1 AS RC1 ����blS=�'C� USS <Dlli <br /> "rV I-7161 '_c,,,rnenc�` 7g'7$ Z-'ol ( close <br /> Inspection Form Included: 0 eG2 L0-I %&-, z8_l <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Insp- eeKor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:40 Incorrect: E X A M P L E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />