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Waste Tire Su. Bey & Inspection Report0lnspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1242145 <br /> CalRecycle 181(Rev. (Cal 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- _7 ,` ! _ © ` Inspection Type(Fill one) <br /> Site Suffix: "` 1 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S u,^ JG 0.�v; G5%4 O CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> PS 'Bo��w 0. .c tC\ <br /> Physical Address <br /> 5\16O W. 1Z <br /> Loi,, Cl- 9sviZ Inspection Date 09 26 <br /> Time In 1 Time Out <br /> Business Rep Title0 AM • AM <br /> I O � � QPM I I ' � QPM <br /> pow 0. w Y.9—`r <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) O \ (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' 1 0 Active Q Passenger 0 Generator 0 Outdoor <br /> - O <br /> GPS Latitude O Closed O Altered <br /> Q Hauler Q Indoor <br /> O Q Inactive 19 Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type(Fill all tha:appty) <br /> Q New Tire Dealer 0 /Wo PoW 0 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 O Agriculture Q Shredder Q 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 /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> 0 Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle q <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EJC7) A <br /> O Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Lu <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> O O Other:§ 11 \ , ` <br /> Comments O`iT ie �Q-S� VC_ NhSO�c_lay _A�� rm 'MSSAcLk "W" <br /> A00 XcP_OILS C5aV1tCQf <br /> Inspection Form Included: Q �4 41,4d0— <br /> Comments <br /> Ta'(ldG —Comments Included: 0 <br /> atu <br /> Business ep's Ig ure Phone Number Inspector'ss Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A M P L E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />