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+ spection Report Number <br /> Waste Tire vey & Inspection Repor0 <br /> CalRecycle State of California 11 - 1242300 <br /> CalRecycle 181(Rev.y(Cal Sup Nay 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 S 1, _ Inspection Type(Fill one) <br /> Site Suffix: L l� ® Routine Q Re-inspection Q Referral Q Observation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identifier: SGI�/1 J O N•1 n tilrn Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address I CS��TO <br /> Inspection Date "_7 <br /> scut o ,-\ (A `�5z3� <br /> i Time In Time Out <br /> Business Rep Title U 0 AM 0 AM <br /> J� (� � diL� 1- I � 0 PM a � S 0 PM <br /> d Lv��' SP G t'1QJ— 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 Q Passenger ! Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GP� Latitude Q Hauler Indoor <br /> o Q Inactive ® 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 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 0 Other a4c, lze(l&d <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 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 <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) 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 In Compliance-No Violations o <br /> Q 1 Q 1 Other:§ <br /> Comments ' z <br /> G 1'_ : l nS �b V 15 <br /> r�S ot2�d = <br /> No � _oAa inns o c o+ conce-f'n -- <br /> Inspection Form Included: Q , <br /> Comments Included: <br /> Business Rep's Signature Phone Number -Inspe6jol Phone Number <br /> INSTRUCTIONS ON BACK Correc . In orrect: R*�fl IEIXIAIMIPILIEI 111213 62081 <br /> White Copy:C Re a Yellow Copy:Operator Pink Copy:LEA ® ■ <br />