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Waste Tire SL- .ey & Inspection Report 'nspection Report Number ■ <br /> CalRecle State of California <br /> cycle Y CalRecycle 181(Rev.10%10) Survey Form - Page 1 I1 - 1177593 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- �A Inspection Type(Fill one) <br /> Site Suffix: '9 6 Z I m 9 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Sari T 0%Y Vh Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> U1-i OV1 0�0'A z s <br /> Physical Address 3 l 0 1 a <br /> Inspection Date Z / ` l / <br /> EelCOAa VA CA X1 320 l <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> 3 •PM * PM <br /> - <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 /> Q Active Q Passenger Q Generator Q Outd000rrl, <br /> O ® Closed Q Altered /UJ)' Nr' ` <br /> GPS Latitude �`� Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q 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 I 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 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 EXT) 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 /> 2 <br /> W <br /> Q Q , 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q -14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments�eyla:�n <br /> No b:o�,o.,�F�o1nS e<- e.rh d� <br /> 2. <br /> Inspection Form Included: < J <br /> p � <br /> Comments Included: X � <br /> 31- ,SC 20CL-LL6g-3211N <br /> Q — <br /> Business Rep's Si ture Phone Number Ins` ctor's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: IEIXIAIMIPILIEI 11 2 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />