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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California T 1 - 1.176699 <br /> CalRecycle 181 Recovery <br /> Survey Form - Page 1 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- SurveyBLUE OR BLACK-INK PEN <br /> Business Profile Inspection Details <br /> TPID- ` t Inspection Type(Fill one) <br /> Site Suffix: 1 l O 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier: SGt��pPtl�fL(1 n W��j 0 CHP 0 CadRecycle0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name I Inspected By Inspector <br /> lI <br /> Physical AWress <br /> C� l�wV`lJ <br /> SInspection Date / (_ 1 <br /> Time In Time Out J <br /> Business Rep Title <br /> Cf(A (n1 f 0P QPM <br /> hCS I�(D �� cr -- - <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Courtt (Whole/PTE) /-,l (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> j(`/'I 0 Active 0 Passenger Generator 0 Outdoor <br /> 0 0 Closed 0 Altered WA <br /> G PS Latitude 0 Hauler 0 Indoor <br /> O ® Inactive ® Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) "Or 1 <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 I C <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other ��c� t f1 I JUnel <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 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m <br /> 0 0 14 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 EXTJ N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 O Other:§ <br /> Comments Q , 1 f� ► 11� <br /> �� �l,N/� 1 ►W �, <br /> LtAl ow� Wa s noW <br /> ) <br /> Noy t O u Uns �5 aJcu,s Lonejfl . <br /> Inspection Form Included: 0 <br /> Comments Included: ® -31 <br /> - %a <br /> Business Rep's Signature Phone Number Ins&jkM/(\ <br /> r' Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: ?V (��) q E X AM L 1 2 3 62081 <br /> . White Copy:CalRecycle Yellow Copy:Operator Pink Cop : ® ■ <br />