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® Waste Tire Su, vey & Inspection Report` 4nspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1196503 <br /> CalRecycle 181(Rev. (CSurvey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey <br /> Recycle) <br /> Part A-Survey _ _ BLUE OR BLACK_ INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � � � � � � - © A Inspection Type(Fill one) <br /> Site Suffix: 1 S Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SCk_V\ Tam %-'h Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> - ► ® l <br /> Physical Address 6_�^ <br /> '& <br /> 7C)o Qc'k \ <br /> Inspection Date Q / z 3 / 1 <br /> cVhP CA 523 Time In Time Out ! <br /> Business Rep ` Title 1 ® O SAM © *AM <br /> Q PM Q 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 /> O <br /> GPS Latitude i Closed Q Altered <br /> Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet ! 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 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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle � <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE n <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 j&In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> I Q vx o "\o�ci �_c a C YCeS HCl Qnv`c�C� <br /> 0 <br /> ��,_�•(�QSa�tiov�� a..►2 �2�r�—'1Mo�� 'ccs Cs. �,yr��:���J�� 4:Skc�.�ey't�c��L <br /> d'A—% r n�.•/l'_P0 , <br /> Inspection Form Included: Q <br /> Comments Included: Q (J��"✓"� Ute—/ "7 0(0 7��4, , <br /> _iaL� •2a J� /b0��� <br /> Business Rep's Signature Phone Number n 's Ignature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: E X AjMjPjLjEj 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />