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Waste Tire SL, vey & Inspection Report �%nspection Report Number a <br /> State of California <br /> CalRecycle I 1 - 1196362 <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- ` h 2 - I Inspection Type(Fill one) <br /> Site Suffix: 1 V I ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S J Du 1/1 1^ C��nni Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical ddres � r�', �\ -11 ` Q 1 G���T <br /> V <br /> Inspection Date ' / 3 I / ( _I <br /> Time In Time Out 1 I <br /> Business Rep Title 0 AM d ll 0 AM <br /> �Uv�eS <br /> 0 PM � S7ISPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) v <br /> B 0 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active • Passenger 4D Generator ® Outdoor <br /> Q Closed O Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> I 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 <br /> 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 <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 EXTj12 <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> N <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 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 f`O't.GL 1 kA2NSv- 1,'Jt, j '01N X t_ 0,-, <br /> l 'Ung_�1 � c�- c <br /> Inspection Form Included: Q 1 �l <br /> Comments Included: 0. — "F -� <br /> $u roes s Signature Phone Number nsp or's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK [Correct:* Incorrect: E AM L 112 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop :Lig/ © ■ <br />