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Waste Tire &.. vey & Inspection Repor�. Inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1230273 <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: b 1 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SCA-Y\ 'To V`� co, Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ��` 777 Inspected By Inspector <br /> Physical Address 3 1 d ' / / kj_ T-U <br /> '�`,/ <br /> Inspection Date <br /> S�c��h °lS215 <br /> Time In Time Out <br /> Business Rep Title *AM ` O AM <br /> I I 3 a O PM l AI'PM <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 /> 0 Active Q Passenger Generator Q Outdoor <br /> O Q Closed Q Altered 'V/f <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ! 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 HAULING AND MANIFEST REQUIREMENTS <br /> �Notice Of Violation Q Extension <br /> Q Q <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 /> PRC§42956-Registration/Decal in Vehicle <br /> QQ 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date MO5 <br /> MO & <br /> / / Fi�1- <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 EX ) N <br /> Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> N <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <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 �LmIn ompliance-No Violations o <br /> Q Q Other:§ \ ` - <br /> CommentsSOY- \,1p— <br /> rV rF-� r <br /> 1 <br /> cavy-1 <br /> n <br /> a - <br /> n Form Included: Q <br /> Comments Included: 0 <br /> - <br /> Business Rep's ignature Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: EXAMPLE1 1112L3] 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />