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Waste Tire SAey & Inspection ReporSinspection Report Number <br /> State of California <br /> CalRecycle I l - 1242148 <br /> ry <br /> CalRecycle 181(Rev. (CalRecycle) Survey <br /> 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- inspection� � -7 � � � � I Inspection 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: SGSOQC)V Co V\ O CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Fe�0.tt <br /> Physical Address 39 <br /> 2 21 <br /> )0. Cac C\'-"-t"a`_\ a-v p,- <br /> S21 Inspection Date , h / b 2- <br /> Time In lJ Time Out <br /> Business Rep Title L^� O AM [ O AM <br /> '9Qw Os- S /\` �. Z 5 0 PM J S a PM <br /> V 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 Q Passenger 40 Generator 0 Outdoor 6 <br /> Q Closed Q Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - O Planned Q OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <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 l <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 0 Other Tcv0ie!R-) SerV1�e T'� �r <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 0 Extension <br /> O Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> O O 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 /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance-No Violations o <br /> 0 Other:§ <br /> CommentsN�%%T{_ p0� e'v%e A_A6 C,)P , Tic <br /> C.,C Cmce,n S <br /> Inspection Form Included: O <br /> Comments Included: 0 `' ��L G q-�0 <br /> Bu'` ess Rep's Si ature Phone Number jnsApe Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A M P L 1 E 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />