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02 Waste Tire Sey & Inspection Report -, Inspection Report Number <br /> CalRecycle State of California 11 - 1242530 <br /> CalRecycle 181(Rev. (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- � � � � � � r _ � � Inspection Type(Fill one) <br /> Site Suffix: J 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local rr,,^, If Referral,choose referral type(Fill one) <br /> Identifier: SG~�l J UL�LtI(1 60 AA 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address - I 0 <br /> Inspection Date <br /> C1 S_ <br /> Time In Time Out <br /> Business Rep Title ^ ®AM l ® AM <br /> � ` 1 l S O PM 1 .0 PM <br /> JGA <br /> Operational Status Tire Type Business Rote Storage Type <br /> 3 <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> (�� <br /> 0 Active 0 Passenger ® Generator 40 Outdoor <br /> 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 IN Dismantler 0 Tire Derived Fuel <br /> 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 /> Q Notice Of Violation 0 Extension <br /> 0 0 <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 <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 <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> Lu <br /> Lu <br /> 0 0 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 ®In Compliance-No Violations <br /> 0 0 Other:§ <br /> Comments n 1 i t <br /> �1 a Vi'o ]A'00-15 OC r.AJpu►S4 CU-nc,Un- <br /> Inspection Form Included: <br /> Comments Included: <br /> usiness Rep's Signature Phone Number Ins a tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X E X A M 1112131 <br /> 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy: <br />