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Waste Tire Sui vey & Inspection Report 'Inspection Report Number ■ <br /> State of California <br /> CalRecycle I 1 - 1177601 <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- 5- 1 Q Inspection Type(Fill one) <br /> Site Suffix: J 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalI �} If Referral,choose referral type(Fill one) <br /> Identifier: S Gl fl_a 1/�,ul (WL1'r l I 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> A �- A Qoss; 9 _ -�- <br /> Physical Address Cy <br /> 511 N � �iJ�vr� lith . <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title I O AM / O AM <br /> PM I S 0 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 /> /J�_/ <br /> 0 Active 0 Pas§enger 0 Generator 0 Outdoor <br /> O 0 Closed 0 AltNN 'erdd' v J rj Ay <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 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ® Other '"lA <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 /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date Ffl / M / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle 4 <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> O 1 O 1 Other:§ <br /> Comments f z <br /> No )j 01a <br /> Fk6kA'k >, na" (4 <br /> Inspection Form Included: 0 <br /> Comments Included: 0 - — - <br /> Busines Rep_'s Sign r �'1�'1/Phone Numb Insp c or's Signature Phone Number <br /> n2081 <br /> INSTRUCTIONS ON BACK [Correct: Incorrect: �!e NJ E X A M L 1 ' 2 3 <br /> 0 White Copy:CalRecycle Yellow Copy:Operator Pink Cop :LE)( <br /> ® 0 <br />