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Waste Tire Su. ,iey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CalRecycle I 1 - 1196473 <br /> CalRecycle 181(Rev. (Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Survey <br /> A- Survey BLUE OR BLACK INK PEN <br /> less Profile Inspection Details <br /> V,O- Inspection Type(Fill one) <br /> Site Suffix: 1 -7 S ' —1 l 0 1` 9 Routine Q Re-inspection Q Referral Q Observation <br /> Local n If Referral,choose referral type(Fill one) <br /> Identifier: 50.Y\ 343 43 r, CO V Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Cz�%.Sv\: � G�v� C\ear�� C �e� � <br /> Physical Addr s 3 — <br /> ?'000 �w ke -'5 <br /> �0f=�4�Ov\ 9520` Inspection Date <br /> Time In Time Out <br /> Business Rep Title AM *AM <br /> C) ' 0 0 O PM O 2- O PM <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 /> Q Active Q Passepqer Q <br /> O Generator Q Outdoor <br /> er <br /> PSLatitude Closed Q AltA)/� <br /> GOQ Inactive Q Truck Hauler Qvo <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Jew 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 • Othero � <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 <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 /> 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 n <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 •In Compliance-No Violations o <br /> Q Q Other:§ _ <br /> \ e_ ` z <br /> Comments .r0\' W��'Y� ''t`�`CP 1 QPM ��n ��j �—S�`!� <br /> 1 <br /> -CLIA,O, ��b� <br /> C p WCe It V\. <br /> __...pection Form Included: Q <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspect is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: g E X A M P L 62081 E 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />