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Waste Tire Su*ey & Inspection Repo Anspection Report Number <br /> Cal Recycle State of California — ■ <br /> CalRecycle 181(Rev. (CSurvey Form - Page 1 11 1210490 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey <br /> Recycle) <br /> 'art A- SurveV BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � � � Inspection Type(Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local -� If Referral,choose referral type(Fill one) <br /> Identifier: SLIn J ChA � U j C(�1A i' 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> 0 rJl r 1'Z S l�lr lZi I�� - <br /> Physical <br /> Address <br /> AV Q, �J <br /> CA `l 533 Inspection Date <br /> Time In Time Out <br /> Business Rep Title <br /> znt� QPM � v � � QPM <br /> S�eJ`n �z►no.�i�� M 7ti�r <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger 0 Generator ® Outdoor <br /> O <br /> GPS Latitude 0 Closed 0 Altered <br /> 0 Hauler 0 Indoor <br /> O 0 Inactive 9 Truck <br /> Longitude - 0 Planned 0 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 <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 0 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 N <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <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 w <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> 0 0 Other:§ 'A <br /> Comments A,0n1 ,JL1n4V-ii S CA.lt,VP-, <br /> N .i.�1��--►bn� r,J ra_1 et�� �i c�r,t�rn <br /> Inspection Form Included: 0 , �/ 'SC)-7 ��Z +�� � <br /> b u �( <br /> Comments Included: <br /> 136siness a S' nature`r Phone Number Inspe is Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BAC orrect: Incorrect: E X I AM I 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy.LE <br />■ <br />