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Waste Tire Su. ✓ey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 1196681 <br /> CalRecycle 181(Rev.y(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- � � � - rem ` Inspection Type(Fill one) <br /> �Site Suffix: ` v 1 40 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Sa-Y\ 'yd�l c.yC I Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V ., �+, "'`7 Inspected By Inspector <br /> `C�Ca.x`S�0(_ on <br /> PhysiAC.�I <br /> cal Addre s ' b1{ v <br /> 'Z'A 0A S. Ccx� <br /> Inspection Date 1 ' 1, Z / 3 <br /> S�GO� 1 72 Time In Time Out <br /> Business Rep Title ' l : 1 C OO PM I S 0 0 PM <br /> � CQ� -C Operational Status T,irre Type Business Role Storage Type <br /> 1, I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) 1 ") l� <br /> ' 40 Active O Passenger 0 Generator * Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude 0 Hauler 40 Indoor <br /> O Q Inactive S Truck <br /> Longitude - O Planned O OTR O End-Use O Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 10 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 O 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 /> Q Notice Of Violation Q Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vdhicle <br /> O Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXfJ <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> O O Other:§ <br /> Comments \\ S �� c� <br /> v� <br /> Inspection7Formincluded: O r� �ComedBusiness Rep's Signature <br /> � <br /> Phone Number Inspe tor's Signature Phone Number <br /> �,{ 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X �J E X A M P L E 1 2 3 <br /> 0 White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />