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% Waste Tire SL ey & Inspection Report nspection Report Number <br /> CalRecycle State of California I 1 - 1177581 <br /> CalRecycle 181(Rev. (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- dd - r Inspection Type(Fill one) <br /> Site Suffix: l (� S -I l I& Routine Q Re-inspection Q Referral Q Observation <br /> Local i If Referral,choose referral type(Fill one) <br /> Identifier: SR V-1 �p G� ry�r Co VY \` O CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Q 2 Inspection Date .Z / l 3 <br /> Time In Time Out <br /> Business Rep Title O AM Q 0 AM <br /> J� 2 O PM 40 PM <br /> O,!' �b,r V 1M ✓ ��lhQ G'r <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole <br /> ® Active ® Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O Q Inactive $ Truck <br /> Longitude - Q Planned • OTR 0 End-Use Container <br /> Business Type(Fill all that apply) <br /> 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 /> O Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O 0 PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle y <br /> IR <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> O Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators `In Compliance-No Violations o <br /> 0 1 Q Other:§ \ <br /> Comments Q <br /> /V c) y,oyek-k-;,ovy9 G-r csea S 0_11� Coy-'cecyl <br /> Inspection Form Included: Q <br /> Comments Included: <br /> .�� Za`T-&38rut� Ztr't- <br /> usin ss Rep's ignature Phone Number Inspector's Signature - Phone Number <br /> �,( 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: � W �J E X A M PJLJEJ 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />