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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Cal Recycle State of California I - 1230342 <br /> CalRecycle 181(Rev.y(Ca[ 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- x/ - o <br /> j Inspection Type(Fill one) <br /> Site Suffix: C ` Q Routine Q Re-inspection ® Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SG�n JOS 1.1•J�l ����� Q CHP Q CalRecycle IS Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> � Inspected By Inspector <br /> Physical Address - l CD 1 ES to 1 ' o <br /> �j r Qv Inspection Date 3 / a " is <br /> Time In Time Out <br /> Business Rep TitleO AM O AM <br /> ' O ® PM I O ® PM <br /> O SLN t C(�S I 00 �Lll1� <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active A Passenger a Generator ® Outdoor <br /> O Q Closed Q Altered <br /> �PS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> it New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 40 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 /> Q Q 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 Q 14 CCR§ 18459-Responsible Entities Complying with Manifesting Requirements Date 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) N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q Q 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 Other:§ l^ <br /> Comments <br /> k �n vVrn� n W: l <br /> q v 1 v,� 101 7 eG <br /> Inspection Form Included: Q 4 <br /> �C- <br /> Comments Included: /Y`i'� <br /> Business Rep's Signature Phone Number Ins ctor's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X EXAMPLEI 1112:N3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />