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0 Waste Tire Su. .iey & Inspection Report Inspection Report Number <br /> Cal Recycle State of California 1210 312 <br /> CalRecycle 181(Rev. (CaRecycle) <br /> ) Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection m , Inspection Type(Fill one) <br /> Site Suffix: I* Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Sar �a�q uih iiAy,r� � 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 0.r Sam s — ' C� `T-T <br /> - — — -- <br /> 2 65 7 -7 S. �o.��o� <br /> Inspection Date <br /> Tr" C A q5- b" <br /> Time In Time Out <br /> Business Rep c ` Title I 1 : O 0 10 AM 0 AM <br /> ` -e—ckof J��`V C" 5Kb �JJ (Ic hr" 0 PM 0 PM <br /> QOperational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger • Generator • Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler • Indoor <br /> 0 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 0 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 /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <br /> r <br /> v <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <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 W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance-No Violations o <br /> Q Q1 Other:§ <br /> i <br /> Comments <br /> VVZ <br /> to Aceas <br /> Inspection Form Included: O . <br /> �" 2oq-y6g,3z� <br /> Comments Included: 0 <br /> Q: iR s ep's Signature Phone Number Insp or's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:9 Incorrect: E X A M P L E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />