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�'sS+33W2i-i:Y4?__-•i�Sil �4::s:{�.i:is•}16t�.Y.ti1i.1{ti•::i f iii+'a'•..1':.:-\111�i:sts�a-_i .��.1..•siv:.:.vu:sw:xs:-av:.o�a ct w.v+aa+sww---s:iw�_+a:us.._L_.•�.......':-..1-:.1��.+. ..r_-s._... <br /> .I <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> Cal Recycle State of California I 1 - 1242318 <br /> CalRecycle 181(Rev. (Ca), Survey 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- ` - QInspection Type(Fill one) <br /> Site Suffix: 1 * Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: San 70 CLU VJ-N �L�(1Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 6 Inspected By Inspector <br /> Physical Addres <br /> (,� %Uresl s Pdo l w C s VW)J 3 9 - <br /> `� (� <br /> i coo <br /> Inspection Date r7 , l <br /> Gc�✓1,�C'p� �� 5 S2o� <br /> Time In Time Out <br /> Business,A Rep TitleAM 1 S 0 AM <br /> Qf � 1 O 5 S QPM r � � J QPM <br /> JU RQ s u'��'`\ ', l 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 Q Outdoor <br /> GPS Latitude O Q Closed Q Altered Q Hauler Q IW JA <br /> oor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned * OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) VbA7AiA <br /> Q New Tire Dealer Q Auto Repair Q 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 ® Other Pool Gl'tiPircVAt 51APP11,e1' <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 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m <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 /> a <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 /> 2 <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 S In Compliance-No Violations o <br /> Q Q Other:§ L L {' t <br /> Comments � liJ_�_lI�'S_�e.(-���I�iCdt.�U� GA{�(�l <br /> Inspection Form Included: Q _ l <br /> Comments Included: ® - avq 7� <br /> Business p's Signature Phone Number Ins ctor s Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: � 7P V EXAM L 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy: <br />