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Waste Tire Sup vey & Inspection Report inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1230225 <br /> CalRecycle 181(Rev.y(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� I Inspection Type(Fill one) <br /> Site Suffix: "� 40 Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: S C',ll._r jQl0 Q\.jt n Cornu 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name V Inspected By Inspector <br /> S S16\ <br /> Sr-ec k- 3 c} - I <br /> Physical Address 0 1 <br /> 0.W` SZ2 Inspection Date I ' 6/ Z <br /> Time In. 1 Time Out <br /> Business Rep 10 AM I d , PM 4 . S; 0 OAM <br /> O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Z <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � <br /> ' 0 Active a Passenger 0 Generator 0 Outdoor y <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor )6 <br /> O 0 Inactive I*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 k­,"oill 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body C --a +rr 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler C *a.--pow 3 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dlrw■ i llor, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler r *-- ­-.port of Tires <br /> 0 0 PRC§42953-Contracts with Reg SIM► reulers. Compliance Deadline <br /> PRC§42956-Registration/Deca+< -ol <br /> 0 0 14 CCR§18459-Responsible Er— ..ow..e-,*Manifesting Requirements Date <br /> M / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program t?wane e...• awRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of CAww .r °^o Logs within 90 days (Required for NOV or EXTJ <br /> vwn <br /> 0 0 14 CCR§18459.3-Retention of CArsommio.os '=ee Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System-Mv*rw-w,% *x Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest Systerr Naste Tire End-Use Facilities w <br /> 0 0 14 CCR§18462-Manifest Syster- -.r Tire Dealers or Waste Tire Generators 0 In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments <br /> CA <br /> ��\�.c �'K V•�Gc.S rlb�ccT` <br /> �O�c2r n <br /> I -} <br /> Inspection Form Include -Alf <br /> Comments Included: <br /> usiness Rep's Signature Phone Number Inspec or's Signature _ Phone Number <br /> INSTRUCTIONS ON BACK Correct incorrect: X EXAM L 1 2 3 62081 <br /> White Copy CalRecc c. Yellow Copy:Operator Pink p LE <br />