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Waste Tire Sui vey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California 11 - 1196563 <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- 1 � � � � - O � Inspection Type(Fill one) <br /> Site Suffix: 7 1 41 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S0.h 'Ton q %3-% Co V"�/ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> S o cVCa.��Ca�n S Nti�C�. <br /> Physical Address <br /> Inspection Date O 1 O V( <br /> C14, Time In Time Out 1 <br /> Business Rep Title s� C 0 AM 0 AM <br /> llo- `nI )�� �e.. /�0.� G. ✓ 0 PM O S 0 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 /> * Active 0 Passenger * Generator Q Outdoor <br /> Q Closed 40 Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive • Truck <br /> Longitude - Q Planned OTR Q End-Use 10 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 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date 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 or EXI) N <br /> Q" Q- 14-CCR-§-15459-.3—Re en i�fon Co prm e ensive Tripogt sfor 3 years —- - - —� <br /> 0 <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 .In Compliance-No Violations o <br /> 01 Q Other:§ <br /> z <br /> Comments \�2d� C �� �"N\ Y�2 <br /> d <br /> Inspection Form Included: Q / <br /> U4/Y 5�-IM A4 <br /> Comments Included: <br /> Busi ess Rep gnature Phone Number Inspe tor's Signature Phone Number <br /> INSTRUCTIONS ON BA K [Correct:0 Incorrect: E X A M P L E 1112 3 62081 <br /> 0 White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © 0 <br />