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Waste Tire Su. Bey & Inspection Repor. Inspection Report Number <br /> CalRecycle State of California I 1 - 1210379 <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- 1 Inspection Type(Fill one) <br /> Site Suffix: g 6 © I 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 5IN Vr Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> S c 1nc S y SA-e-wt S � q l d � fV�,(}'�'�' l� <br /> Physical Address - <br /> �ZSd ��.7!-Vh.Q►1 ��. 2 <br /> C� 152(0 <br /> Inspection Date S -2- <br /> ° <br /> Time In Time Out <br /> Business Rep Title I I O AM O AM <br /> 0 P ' 0 0 P <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) /1� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' ([.J 0 Active Q Passenger 9 Generator Q Outdoor <br /> O Q Closed Q Altered A) <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned • OTR Q 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 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder * Other <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 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / M / 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 /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <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 .In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments �q 1 <br /> ` K-O.ti T��'�2 1 0.S� ��� �YDS P���O Y� CVCfJ✓L� C9✓1 "���S C�a� r <br /> �o �nS pf Are_a5 <br /> Inspection Form Included: Q <br /> � 61 to l qq l l . � coq-�(68�,3z8y <br /> Comments Included: Ause <br /> -Rep's Signature Phone Number Insp tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: g E X A M P L E 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />