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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> cal Recycle State of California 11 -1176451 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <br /> Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> BLUE OR BLACK INK PEN <br /> iness Profile Inspection Details <br /> . <br /> -ID- � � ^ � O O I� - T I Inspection Type(Fill one) <br /> Site Suffix: I -1 U ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Suo J ��.q��n COu� O CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 10vim 'J <br /> Physical Address (� I V 1 VCS <br /> Svku \ b�� �n- / <br /> Inspection Date %7 <br /> Time In Time Out <br /> Business Rep Title I O AM O AM <br /> ® PM V ® 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 Passenger Q Generator Q Outdoor <br /> Ci ISClosed Q Altered W A �� <br /> GPS Latitude N Q Hauler O Indoor <br /> D Q Inactive O TrucK " <br /> Longitude - Q Planned —�0 OTR - O End-Use O Container- <br /> Business Type(Fill all that apply) <br /> 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 /> Q Notice Of Violation � Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / m / m <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 EXl) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> O Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities u, <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:§ 1 /�. _ - Ll 1 ( I <br /> Comments�01�1�\ 1. t' �Jt ��)v 111�(OPLl�IU� (1�l) U1 ��15 6��,,k� C(c1( "TOV`lA 1I tiUI <br /> 1 ', n D f�Gs�j� �-lts � 1 u �'� fl 1 9 -11� b MGCI.'rcS� <br /> �pection Form�nc <br /> ncluded: Q <br /> Comments luded: <br /> Business Rep's Signature Phone Number Insp or's Signature _ Phone Number <br /> �,-�( 62081 <br /> INSTRUCTIONS ON BACK FCor�re�ceIncorrect: X � N E X A M P L E 1112 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />