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Waste Tire Su. ✓ey & Inspection Repori "Inspection Report Number <br />CalRecycle State of California 11 -1177699 <br />CalRecycle 181(Rev.H0) Survey Form ® Page I <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />'art A - Survey <br />V <br />A <br />BLUE OR BLACK INK PEN <br />Business Profile <br />�� / <br />Inspection Details <br />j <br />TPID - o <br />Site Suffix: �, (� <br />Inspection Type (Fill one) <br />cA <br />d <br />a ( <br />(0 Routine Q Re -inspection <br />Q Referral Q Observation <br />Local <br />Identifier: SGS V` <br />7C:(k"I-t, 60"4— <br />v <br />If Referral, choose referral type (Fill one) <br />Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br />Business or Facility Name <br />Q <br />Inspected By <br />Inspector <br />Time Out <br />Q <br />Business Rep <br />Q <br />Physical Address <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q <br />/ <br />3aS`t &, z I +Ovxc,-rDv (st-- , <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />Inspection Date(7 <br />�� / <br />C.. e- / <br />j <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />cA <br />r5doG <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q <br />Q <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />Q <br />Time In <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />Time Out <br />Q <br />Business Rep <br />Q <br />Title <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q <br />0 AM <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 AM <br />// <br />��GLYI <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />Q <br />Q <br />o <br />O ®PM <br />l Z Z cJ ® PM <br />�f/ <br />n <br />✓ <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Tire Count (Whole/PTE) <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />® Active <br />® Passenger <br />* Generator <br />Q Outdoor <br />GPS Latitude <br />Q Closed <br />Q Altered <br />Q Hauler <br />®Indoor <br />Q Inactive <br />Q Truck <br />Longitude <br />- <br />O <br />Q Planned <br />Q OTR <br />Q End -Use <br />Q Container <br />Business Type (Fill all <br />that apply) <br />Q New Tire Dealer <br />Q Auto Repair <br />Q Trucking Fleet <br />Q Government Q Retreader ® Dismantler Q Tire Derived Fuel <br />Q Used Tire Dealer <br />Q Auto Body <br />Q Car Dealer <br />Q Collection Q Crumb Rubber <br />Q Service Station <br />Q Hauler <br />Q Agriculture <br />Q Shredder Q Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />Q <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q <br />Q <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />Q <br />Q <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />Q <br />Q <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q <br />Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />Q <br />Q <br />Other: § <br />Comments <br />Inspection Form Included:-(_) <br />Comments Incl ed: <br />B sin <br />INSTRUCTIO S ON BACK <br />Whi <br />Pink <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Date / <br />(Required for NOV or EXT) <br />Q Referred / CalRecycle Enforcement <br />0 In Compliance - No Violations <br />Phone Number <br />62081 <br />® ■ <br />CJ <br />a <br />N <br />0 <br />W <br />tureN, <br />Phone Number <br />Corre e I <br />orrect: <br />Copy: CalRecycle <br />Yellow Copy: Operator <br />Pink <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Date / <br />(Required for NOV or EXT) <br />Q Referred / CalRecycle Enforcement <br />0 In Compliance - No Violations <br />Phone Number <br />62081 <br />® ■ <br />CJ <br />a <br />N <br />0 <br />W <br />