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Waste Tire SMy & Inspection Report spection Report Number <br /> CalRecycle State of California 11 -1176471 <br /> CalRecycle 181(Rev. (Ca] 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- i ^ 1 5 0 _7 - Q Inspection Type(Fill one) <br /> Site Suffix: t{v� 16 l * Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 1(� �tL:f.�� Cc>�/yt-lv� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name VV Inspected By Inspector <br /> C vJ��i - n.�vtzz�, cl - 1 C) l 74l6s� k.rn.1a 1 <br /> Physical Address ,QQ rw <br /> Inspection Date * a— / <br /> ILt <br /> Time In Time Out <br /> Business Rep Title ® AM O AM <br /> l <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 /> l IP Active ® Passenger ® Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q 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 Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body ®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 /> 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 /> Q Q 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 /> 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 ®In Compliance-No Violations o <br /> 01 Q 1 Other:§ <br /> Comments <br /> Inspection Form Included: Q _ <br /> Comments Included: ®— `z lP �s -- — �'� !�-7 <br /> Business Rep's Signature Phone Number 1 spe to i ur Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E 1 2 3 <br /> SWhite Copy:CalRecycle Yellow Copy:Operator Pink Co y: <br />