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Waste Tire Sui ve & Inspection Re oro'nspection Repc t Number <br /> CalRecycle y p p _ <br /> y State of California I 1 1230406 <br /> CalRecycle 181(Rev.y(Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Sart A- Survey _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I 0 I ' _ O Inspection Type(Fill one) <br /> Site Suffix: 10 Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocaleIf Referral,choose referral type(Fill one) <br /> ` <br /> Identifier: S0. ,.,r,ot V`r\ 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Aw.eVM,- �Z-e4�_ ��� �� °I - ATfiv <br /> Physical Address <br /> �'A 4Q <br /> �rCt� �� � ���� Inspection Date 0 � � -Z � <br /> 7 Time In Time Out <br /> Business Rep T}le ^�_ O AM O AM <br /> Crud• C&A'a,+TTawF7r � U � � PM � © � 4WPM <br /> W6,�L. <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 9 5 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active 0 Passenger 0 Generator ® Outdoor <br /> O 0 Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O <br /> Q Inactive 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 • 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 /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 EX7) N <br /> a <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 I o <br /> 0 0 Other:§ <br /> Comments <br /> Ck Cpy\,ce.PVx <br /> Inspection Form Included: 0 Z 0 0 ao36 u p/ J� ^ E/ <br /> Comments Included: I ` — — - !"_'� �— <br /> c/' <br /> usiness Rep's Signature Phone Number Inspec or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: M A E X AJMJ P JLJEJ 1112 131 <br /> 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ■ <br />