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O Waste Tire Sup Bey & Inspection Report spection Report Number <br /> Cal Recycle State of California I 1 - 1177839 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <br /> 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- n t 1 _ I Inspection Type(Fill one) <br /> Site Suffix: `� "� ® Routine Q Re-inspection Q Referral Q Observation <br /> Local �(' J l If Referral choose referral type(Fill one) <br /> Identifier: SC,t(1 JoCL j/),1 n CUUn � Q CHP � Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> � 1�� Inspected By Inspector <br /> VIII �0 6 � V3 5 - 1 o <br /> Physical Address <br /> ,OSS b 1 G1 m on C A i , �v <br /> Inspection Date / �1 / I 3 <br /> Time In Time lOut <br /> Business Rep Title` 11_ C O AM r� O AM <br /> SV eXk C� ��' AsS � ( J t PM d 0 PM <br /> -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (FII all that apply) (Fill all that apply) (Fill all that apply) <br /> Active Q Passenger 9 Generator Q Outdoor <br /> O Q Closed Q Altered N <br /> GPS Latitude <br /> O Q Inactive 0 Truck Q Hauler Q Indoor <br /> Longitude - Q Planned ® 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 I <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other NAM �140Q 7OJILAJc/"' <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 o <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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q o 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 EX7) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> Q o 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q o 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:§ <br /> Comments ` I , I I N <br /> 7r irfl�i <br /> ioa,S of cA,CXCAs o, umcern- <br /> Inspection Form Included: O ' <br /> Comments Included: a( , IX; QIA <br /> Business Rep's Signature Phone Number Ins tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: EXAM I P E 12 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy: <br />