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Waste Tire SUFvey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1245007 <br /> CalRecycle 181(Rev. (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- � D ('� 1 � / - O � Inspection Type(Fill one)p Q Q <br /> Site Suffix: -1 ""� b Routine Re-inspection Referral Observation <br /> Localt� If Referral,choose referral type(Fill one) <br /> Identifier: 5Gy_x 3'e' N-1- <br /> `� GVH-}�1 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or�Facility Name W `, Inspected By Inspector <br /> PhysicalAddresssc�� 9(30(- ��0� 3 ff - 1T 1 v <br /> /vl <br /> I o G`,l vena cam- �v <br /> 2 Inspection Date S <br /> 6152-03TimeIn Time Out <br /> Business Rep Title O AM 'J C O AM <br /> 2 ' Q S I PM 4 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 40 Closed Q Altere Nrr N[ <br /> GPS Latitude N Q HauleF Q Indoo <br /> 0 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 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 46 Other qc ocn. CO. <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 /> Q Q <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 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 N <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 o <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 I*In Compliance-No Violations o <br /> Q 1 Q Other:§ 1 <br /> Comments0Q..+ 11"QL��11 <br /> LIS 13313—a1 <br /> Vhf 0mrsm- N A366 191�_D �e C_["e_� , <br /> Inspection Form Included: Q <br /> Comments Included: Q !J� <br /> Business Rep's Signature Phone Number Inspect 's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: EXAMPLE 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />