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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of California I 1 - 1196322 <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- Inspection Type(Fill one) <br /> Site Suffix: 6 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local `` If Referral,choose referral type(Fill one) <br /> Identifier: SQ VA �vG-��✓�- Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> To s 1 VM e CA U - J <br /> Physical Address ' ( A <br /> (� Inspection Date / v / I e` <br /> � Time In Time Out <br /> l <br /> Business Rep Title O AM -3 <br /> O AM <br /> R ' '1 S ®'PM J OPM <br /> el 4 -ave .5 Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) J 0 <br /> ® Active ® Passenger (jo Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude .hauler Q Indoor <br /> O Q Inactive Q Truck ' <br /> Longitude - Q Planned Q OTR ® End-Use Q Container <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 0 Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V_[AtHAULING 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 /> 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 EXE n <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years _ <br /> 0 <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> W <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 J&In Compliance-No Violations o <br /> Q Q Other:§ <br /> z <br /> Comments <br /> Inspection Form Included: <br /> Comments Included: 7 _ <br /> Business Rep's Signature Phone Number I pe or's tur Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: E X A M P L 1 2131 62081 <br /> ■ White Copy:CaIR cle Yellow Copy:Operator Pink Copy: EA © ■ <br />