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Waste Tire Su, vey & Inspection Report Inspection Report Number <br /> CalRecycle State of California 11 - 1229922 <br /> CalRecycle 181(Rev.y(Ca[ 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- _ O I Inspection Type(Fill one) <br /> � � � � � <br /> Site Suffix: * Routine Q Re-inspection Q Referral Q Observation <br /> Local �, If Referral,choose referral type(Fill one) <br /> Identifier: SGI� 1 dCCf V\.Y\ Co v r Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name v <br /> Inspected By Inspector <br /> Physical Address „ x <br /> �`, q Inspection Date I � <br /> Seo Time In L Time Out <br /> Business Rep Title O AMO AM <br /> ,J <br /> /� �PM � 2_ � � PM <br /> Cl�i vr.R. ��lc>..C-2'Z ��N Y�e..� <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/ t ' n (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> "F (� * Active Q Passenger 0 Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive 0 Truck <br /> Longitude - Q Planned • OTR Q End-Use a 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 9 Other 'T"i V-_CteS? <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 M / M / FF] <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <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 U) <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 yjzv` `� t __ a�� <br /> o� "C v`l t lr���r 1 <br /> & \ c�� —�X .��--cam —� <br /> kA i <br /> Inspection Form Included: Q / <br /> �- <br /> Comments Included: - <br /> iness Rep's gn ure Phone Number Inspect Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: Jjj � jjjjE X A M P L E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />