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Waste Tire Survey & Inspection Report .nspection Report Number <br /> CalRecycle State of California181R I 1 1177834 <br /> CalRecycle 181(Rev.y(Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK_PEN <br /> Business Pi ofile Inspection Details <br /> TPID- 1 � /� l") � 1--t © � Inspection Type(Fill one) <br /> Site Suffix: ol ( ! ® Routine Q Re-inspection Q Referral Q Observation <br /> Local e- ' If Referral,choose referral type(Fill one) <br /> Identifier. S o Qa��„` C� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name J <br /> Inspected By Inspector <br /> NmeCI(_k , 7" r� d_T5u c� RePa;r <br /> Physical Address 3 1 - 1 U <br /> SaM S _ G a'd0 S�_ <br /> Inspection Date 1 / 3 rI / ) 3 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> M 2 ' 'a O ® PM 1 ' v � PM <br /> -- <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 3 '_7 <br /> _7 _0 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active ® Passenger ! Generator • Outdoor <br /> D Q Closed • Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive • Truck <br /> Longitude - Q Planned Q OTR Q End-Use Container <br /> Business Type(Fill all that apply) <br /> _' New Tire Dealer ® 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 /> 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 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or E)C7) N <br /> 0 <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 W <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q 1 Q Other:§ <br /> Comments Al;rA_' ugk4 ; I tDn AWL 1 S Aal ra"kfilt . <br /> N <br /> 5 pdlm <br /> Inspection Form Included: Q n�n r� ( R 1 <br /> Comments Included: 0o'—� -L— /O4 °��' g� m <br /> Business Rep's Signature Phone Number Insp tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X0 V E X AIM P L E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop .L <br />