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Waste Tire Survey & Inspection Report inspection Report Number <br /> State of California <br /> CalRecycle <br /> calRecycle 181(Rev.10110) Survey Form - Page 1 11 1177508 <br /> Dept.of Resources Recycling and Recovery(calRecycle) <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- r) <br /> G _ O Inspection Type(Fill one) <br /> Site Suffix: I ® Routine Q Re-inspection Q Referral Q Observation <br /> Local �- I If Referral,choose referral type(Fill one) <br /> Identifier: SGS J <br /> Business or Facility Name "l�/A LAI J-\� �vL�� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> � Inspected By Inspector <br /> Cwt _ I <br /> 5� e� LLL f�. � �-er � 3 - U <br /> Physical Address s CQ�T(D <br /> Inspection Date / t -5 l <br /> CAGs�� 3 <br /> Time In Time Out <br /> BusinessRepTitle\ c 0 AM )� O AM <br /> 0 PM �. � V GPM <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 /> I♦ Active Q Passenger 0 Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude � Q Hauler Q Indoor <br /> O Q Inactive • 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 ®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 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 / 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 o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities u, <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 O � �►1US�C. �l Pi <br /> 10 c fu t��Q� cion ter n <br /> Inspection Form Included: Q J <br /> 17 <br /> Comments Included: <br /> t N <br /> u as a gnature Phone Number Insp or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X0 V] <br /> E X A E1 1112131 <br /> 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop <br />