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Waste Tire St.. vey & Inspection Report Inspection Report Number ■ <br /> cal Recycle State of California I 1 - 1226596 <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- Inspection Type(Fill one) <br /> Site Suffix: , �> , (� ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SCA Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name l <br /> Inspected By Inspector <br /> Physics dress <br /> 0�Vs CIL El 9-in-M071-4— <br /> c,� <br /> L� 5a©5- <br /> Inspection Date 1 U z / <br /> -, <br /> Time In Time Out <br /> Business Rep Title 1 G 0 AM ®AM <br /> , , 11 gelAw "rJ4Vri�✓ �L ' t J 0 PM I 5 0 PM <br /> Uhc�,G�f Wyx lG irvr I,JYttG -- <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active ® Passenger ® Generator Is Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q 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 /> ® 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 A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q 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 / [—n <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7j N <br /> a <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <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 <br /> ®In Compliance-No Violations o <br /> Q 1 Q Other:§ <br /> Comments rl' Del 1Lwser v3 C /Z A& ►�' `� �72JY1 s lZt� <br /> .�,�cz � � �ctG�� "7�i�,vt GJk r��3 �n r.��✓ ,?c_..J �c..n�r c�s7�t,r,b . <br /> 16 <br /> 961 O - -TP ;V-- 10`79002-7 lbw lo-Ne e_--) <br /> Inspection Form Included: Q 5t g <br /> Comments Included: Q d� �`..1� `1-u1A64 -74, "�6U L6 <br /> Business gnature Phone Number I s i ature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: (X1 i q �mXjAjM_rPjLjEj 11F2F3162081 <br /> ■ White Copy:CalRecycle Yellow I y:Operator Pink Copy:LEA © 0 <br />