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Waste Tiriv Survey & Inspection Rep3rn Inspection Report Nurnber ■ <br /> CalRecycle State of California _ I 1 - 1226609 <br /> CalRecycle 181(Rev.10/10) Survey Form Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> BLUE OR BLACK INK PEN <br /> Part A-Surve <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: �t d 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalC �� ' "n If Referral,choose referral type(Fill one) <br /> Identifier: SGS VN X�C CI L 1� wV► l` Q CHP Q CaJRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 61� H"1 C� L CAZ� <br /> Physical Address �"rt2�I►'l IO�.�e�. <br /> 1331 s- 4ck L . <br /> Inspection Date <br /> L CA <br /> "'ol,9 1- Time In Time Out <br /> Business Rep Title O AM '7 O AM <br /> Jctee4- wr oze� 1 1 5 ®PM 3 7 # PM <br /> grailc `S G✓!'i'3QY 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 /> ® Active 0 Passenger ® Generator ® Outdoor <br /> Latitude Q Closed Q Altered <br /> GPS LatQ Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet ® 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 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 /> QQ 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <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 EXTJ 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 /> a <br /> W <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <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 /> -_— - <br /> Comments <br /> Inspection Form Included: Q <br /> BAM, I Qz©q-ewcy-3' <br /> Comments Included: <br /> "inessRatur Pon®Number I s cto ' i atur Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:, Incorrect: E X A'M P 1.1T273 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink CopyVE ■ <br />