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Waste Tire Survey & Inspection Report inspection Report Number ■ <br /> State of California <br /> CalRecycle 11 - 1196378 <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- 15 t_7 5 - O Inspection Type(Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: Sj,�(�_TQ 1 C\ 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> e Inspected By Inspector <br /> LA; A47 VNfwV1.i <br /> Physical Address <br /> X30 &4�1l sow A A- �a <br /> Inspection Date � / 1 1'1 <br /> Time In Time Out <br /> J <br /> Business Rep Title O AM O AM <br /> v 0 PM 0 Q ® PM <br /> ct 6� S�,'� � � C7 t�-fie 1— <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) i q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 (P Active ® Passenger ® Generator 0 Outdoor <br /> O <br /> GPS Latitude 0 Closed 0 Altered <br /> Q Hauler 0 Indoor <br /> O 0 Inactive 0 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 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 /> 0 0 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 a <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> a <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities m <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> ®In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments ''\C, X_`0 CA(S lc_' 1 tc� <br /> 1 <br /> �T►'UnS ar ct(cet.s o,� (,gym rn- <br /> Inspection Form Included: 0 (/ (,f r <br /> Comments Included: �(-_` <br /> B s' ess p's Signature Phone Number Ins toy's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: EXAM L E 1 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co © ■ <br />