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Waste Tire Survey & Inspection Report "inspection Report Number ■ <br /> CalRecycle State of cle 181(R I 1 ' 1196388 <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- e p 3 _ Inspection Type(Fill one) <br /> Site Suffix: I o 0 Routine Q Re-inspection Q Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SG n J(�C&9 VN 1 Lln i 0 CHP Q CalRecycle 0 Complaint Q Educational Visit 0 Other <br /> - -- -1/l <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address 1 Es wTTO <br /> 35 a"I 0,r Vc fir_ <br /> Inspection Date <br /> 1 / 0 <br /> Time In Time Out <br /> I <br /> Business Rep Title i O AM O AM <br /> J <br /> ��77 L I ® PM O V ® PM <br /> L �J on K9-M,n �'0-� S 74z f1)U„cv el' <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) p (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' U 0 Active ® Passenger 0 Generator 40 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 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 • 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 Notice Of Violation 0 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 /> PRC§42956-Registration/Decal in Vehicle <br /> 0 Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <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 EXT) 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 /> 0 Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 In Compliance-No Violations <br /> 0 0 Other:§ <br /> Comments <br /> Flo vola ' v-,s of uSe,rn.$ ct�,<<rn- <br /> Inspection Form Included: ;� 1 _ <br /> Comments Included: <br /> B ss Rep's Signature Phone Number. Ins a tor's Signature Phone Number <br /> INSTRUCTIONS 04 BACK Correct:0 Incorrect: X�0 NJ E X A M I L I 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink C z <br /> V <br /> ® 0 <br />