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Waste Tire S_ - vey & Inspection Repor L Inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1176575 <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-� - 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: Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 V', <br /> /n� ,.GVvt�I� vh <br /> L n �P Inspected By Inspector <br /> Air P,-ocl. c_ S w1,1 t34-5 <br /> Physical Address 3 ) - <br /> Inspection Date C) i� <br /> (;9+0('1't-a3 c-A qo(. <br /> Time In Time Out <br /> Business Rep Title / ^� 0 AM 0 AM <br /> Arun ►tilatnc,6,-5ir►Stti pjc"V-J, � �t <br /> ACJirr i Q rX O 0 PM I o2 1 � � PM <br /> Operational Status Tire Type Business Role Storage Type <br /> a,( <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> (T/J <br /> ® Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned ® OTR • End-Use Q Container <br /> Business Type(Fill all that apply)------- --- - --- -- —- — l i F N/A <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 ® Other Olxve'r PLP'Lt <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 Q Extension <br /> Q Q 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 DateM / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle &q <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) 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 7 <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 ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> ��/(r I'lr7lr-�a0 <br /> Inspection Form Included: Q ea <br /> ®_�G *,t.re <br /> j � ..- —Comments Included: - <br /> Buslness Rep's iP�ione Number nspector',Signatur Phone Number <br /> --�-------- -- <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X J E X A L 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co :L © 0 <br />