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02 Waste Tire S6, vey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CalRecycle I 1 - 1196335 <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 Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: 1 ci a 6 5 L Is Routine Q Re-inspection Q Referral Q Observation <br /> Local \ //�� � If Referral,choose referral type(Fill one) <br /> Identifier: S&Vk J((aGlCbt tl'`- "�li✓L Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> V1{T—'. <br /> Physical Addret ss�Z �i `J L - L 0 / L"L/4 <br /> q�oL i/z A) . 4) , l soy-, �7 <br /> Inspection Date / 2 <br /> ( Time In Time Out <br /> Business Rep Titlej ®AM &AM <br /> [ l 1 J 0 PM l i 1 J� Q PM <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/PTE) �/ <br /> r I' 10 ® Active 0 Passenger ® Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude ® Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR ® End-Use Q 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 ® 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 Q Q Notice Of Violation Q Extension <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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / m / m <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 EX7 <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years 0 <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q O 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 <br /> ®In Compliance-No Violations o <br /> Q Q 1 Other:§ <br /> Comments <br /> V N <br /> Inspection Form Included: <br /> Comments Included: Is <br /> Business Rep's Signature Phone Number I p to,' i atur Phone Number <br /> INSTRUCTIONS ON BACK Correct:10 Incorrect: g E X A M L1112131 <br /> 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co y:L ® 0 <br />