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160 <br /> Waste Tire-burvey & Inspection Rep"Inspection Report Number <br /> CalRecycle State of California r _ 1176400 1 7 (� 4 0 <br /> CalRecycle 181(Rev.y(Cal Survey Form - Page 1 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- inspection/r, Inspection Type(Fill one) <br /> Site Suffix: �J o I Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SG n �a(�( (("'M1 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name lInspected By Inspector <br /> A. �,,� ��� � I��I1 ITT)G� <br /> Physidal Address L � ]} <br /> Inspection Date 1 <br /> Time In Time Out <br /> Business R 4 C-1 Title / 0 AM ` c 0 AM <br /> V 0 PM 1 J O ® 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 IS, Passenger ® Generator 0 Outdoor <br /> 0 0 Closed 0 Altered NIA <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive &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 J@ Other L an aSL4 Pe%t.t"�a j ' IteJ1'Als <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 0 0 Notice Of Violation 0 Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 00 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 1.4 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 /> a <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 /> 0 0 Other:§ a <br /> Comments (] 14\ S u j� 1 �-4' on )3 [, <br /> — )INL&�1 n1a� ne, WUS no�,� <br /> N o "nn-5 C wf0 us <br /> Inspection Form Included• <br /> Comments Incl ed: ��-3S J D <br /> Bus' ess Rep's Signature Phone Number Ins tor's Signature _hone Number <br /> INSTRUCTIONS ON ACK Correct: Incorrect: � ® v E X A M E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cot&/ <br /> LE © 0 <br />