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Waste Tire Se` ey & Inspection Repor; Inspection Report Number <br /> CalRecycle State of California 1177590 <br /> CalRecycle 181(Rev. y(Co) Survey Form - Page 1 <br /> j11 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-SurveV BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- - Inspection Type(Fill one) <br /> Site Suffix: , 3 '1 * Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identifier: SA,,\ �,A V V.\ c 0y� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> l2eo�c�,yy `Ct'c�,ns p <br /> or\-e'_V:oh � al <br /> Physical AddFess l �SC� �4_0 <br /> 2�1 l Cal'�' -n <br /> Inspection Date '7 � � ` � r <br /> S �oc\.�.�C,r C152-06 <br /> Time In Time Out <br /> Business Rep ` Title �7 c 0 AM 0 AM <br /> SCCA �� �j c'c�- W�n e'�' Z ' d 5 • PM 3 ' D 0 8 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 /> 14 0 Active 0 Passenger 0 Generator ® Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive ®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 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 /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or E?C7) 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 /> LU <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 /> Q0 1 Other:§ <br /> Comments ?�:00 OV\, <br /> N ve4 <br /> Inspection Form Included: 01W//A6f �/�2` )� <br /> Comments Included: -L d, �3 <br /> usiness ep's Signature Phone Number Insp or's Signature Phone Number <br /> 1_111, <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* in rect: M EXAM P-L E 1 2 3 <br /> c r <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop .LEA <br />