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0 Waste Tir 3 vey & Inspection Re, l Inspection Report Number ■ <br /> Cal Recycle state of California I 1 - 1177579 <br /> CalRecycle 181(Rev.y(CalRecycle) Survey <br /> 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 Q ` , � o � 1 Inspection Type(Fill one) <br /> � � <br /> Site Suffix: I 1 "� 1* Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local 0— If Referral,choose referral type(Fill one) <br /> Identifier: &y\ -) P" V 0 Vy�.�y 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> '�>kc,cVVinv, e2cyLl,K\ -.C%,C <br /> Physical Address 31 <br /> 15 3 3 W aA-e_(Ado )?-&, l r <br /> G Inspection Date � / 1 � / ' <br /> 5}�C� 2 Time In Time Out <br /> Business Rep Title A[M11 C ® AM <br /> Z 0 �� <br /> � S � QPM <br /> ----- Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 21 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> GPS Latitude O0 Closed 0 Altered <br /> 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned • OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other ec- <br /> �>n Ce1n�Cr <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m " <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention-of Comprehensive Trip Logs for 3 years. <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities m <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> O 0 Other:§ <br /> n � <br /> Comments ZO-Aiv�2, U9c,�Sr� Aare (nv\2 Or` . S <br /> Inspection Form Included: 0 . <br /> Comments Included: <br /> � i �� 7 zdq-"1 G4—3z2 <br /> uslness Rep's Sign Phone Number Inspec or's Signature Phone Number <br /> INSTRUCTIONS N BACK Correct:0 incorrect: M � � EXAMPLE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />