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■ Waste Tire S Vey & Inspection Repor Inspection Report Number ■ <br /> CalRecycle State of California 11 - 1242396 <br /> ry <br /> CalRecycle 181(Rev. y(CalRecycle) Survey <br /> Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recove (CalRecycle) <br /> Part A- Survey _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ` Inspection Type(Fill one) <br /> Site Suffix: � !,7 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local C If Referral,choose referral type(Fill one) <br /> Identifier: ?0—y\ _3_6�V�Y\ Covv" 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 5s�tk� 3 1 1 O <br /> 5 3o Qoc� o 1 � sswa�f <br /> Inspection Date O / 0 5 1 <br /> S�oc4ko� C a1s2o3 <br /> Time In Time Out <br /> Business Rep Title [� 0 AMC 0 AM <br /> ' � ✓ 0 PM � � ✓ 4,PM <br /> `Ck �h 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 /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered m 1A <br /> GPS Latitude 0 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 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 m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 /> '010 Other:§ <br /> Comment <br /> V\e ohekco � <br /> 0.XA- fie— �o ', <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> Busin sp <br /> 's Signature Phone Number Inspec is Signature Phone Number <br /> �-�( <br /> INSTRUCTIONS ON B7hite <br /> Correct:O Incorrect: X � rJ E X A M P L E 1 2 3 62081 <br /> ■ Copy: a ecyc e Yellow Copy:Operator Pink Copy:LEA ® ■ <br />