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J <br /> Waste Tire Survey & Inspection Repu, t Inspection Report Number <br /> CalRecycle State of California 11 -1.1764U5 <br /> CalRecycle 181(Rev.y(Cal Survey Ff1rt ,. Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) V M� W jj �\JJ <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- - O I Inspection Type(Fill one) <br /> Site Suffix: l l ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalC If Referral,choose referral type(Fill one) <br /> Identifier: SOo od��1 (1 (vu�� Q CHP Q CalRecycleQ Complaint Q Educational Visit Q Other <br /> Business or Facility Name n Inspected By Inspector <br /> 1 <br /> ��� d- A� v SQcvtic� _ U <br /> Physical Address <br /> 0r� U`•�ti�, <br /> � Inspection Date <br /> 1 ! Time In Time Out <br /> Business Rep F Title l 1 0 AM 0 AM <br /> PM O ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> a v 3 <br /> * Active 1101 Passenger ® Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned 0 OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer 46 Auto Repair Q Trucking Fleet O Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer O Collection O Crumb Rubber <br /> ® 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 O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 O PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / m <br /> Q 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 N <br /> O Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ w <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> ®In Compliance-No Violations o <br /> Q 1 O Other:§ <br /> 1 1 - z <br /> Comments , �y� I N <br /> + r bOW n <br /> Inspection Form Included: 0 <br /> Comments Included: <br /> Busine Rep's Signature Phone Number Insp or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A L 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink V/dA ® ■ <br />