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Waste Tire Survey & Inspection Report nspection Report Number <br /> CalRecycle State of California 11 e 1177860 <br /> CalRecycle 181(Rev. (Ca <br /> urVey 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- O O � Inspection Type(Fill one) <br /> Site Suffix: �[ 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local l l L If Referral,choose referral type(Fill one) <br /> Identifier: San V 0 u 1^ C(�u�1{ 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> 1- l Inspected By Inspector <br /> ItNul_ UoVrLaII' Si�� _ <br /> Physical Address <br /> (A ` s3,D I Inspection Date <br /> J Time In Time Out <br /> Business Rep Title AM Q AM <br /> �� 11 <br /> IVB 4n AI k �foSlv`�111 QPM I a b � PM <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 0 Outdoor <br /> O ® Closed 0 Altered h N <br /> GPS Latitude O 0 Inactive 0 0 Hauler 0 Indoor <br /> Truc��� <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 0 Notice Of Violation 0 Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 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 EXE N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> LU <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 O 1 Other:§ <br /> Comments t Ill l0^' _ 7! _ �!f)(, UA3 0C� N <br /> 9i0 p1 u (CIA3 <br /> aulN no ty `-- zJ z,5oo S, NoI bfTtcv-m <br /> a� Nv r - ur����l •� �� a 'vim, Clv�Se�P��, <br /> Inspection Form Included: 0 —20 <br /> Comments Included: 0 t / V <br /> Business Rep's Signature Phone Number Insp c or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: {� EXAM L 112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink C y: A ® 0 <br />