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0 Waste Tire Sw vey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California 11 - 1226511 <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 Type(Fill one) <br /> Site Suffix: c) 1 - f 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SVA �( LC/�,(' ,,f} 'iiYl Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> P -1 15 �;.�,� 3 � _ r � ) r <br /> Physical Address / <br /> A ..o Inspection Date Z <br /> CA C�Z!S <br /> Time In Time Out <br /> Business Rep Title 0 AM �r1 Q AM <br /> �Iv� �CC���"Z� �° �eriC/►� � � � O QPM ' Z_ � 6J 46 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 /> IS Active ® Passenger ® Generator At Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR ® 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 /> ® Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q 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 /> 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 /> PRC§42956-Registration/Decal in Vehicle <br /> QQ 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date / / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle �flo <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) N <br /> a <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 /> 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 = <br /> Q In Compliance-No Violations o <br /> Q 1 Q 1Other:§ <br /> Comments <br /> Inspection Form Included: <br /> Comments Included:�j — zj- - <br /> Business Rep's Signature Phone Number Si a re Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 incorrect: E X A El 11 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop A ® 0 <br />