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Oa Waste Tire Su,vey & Inspection Report Inspection, Report Paurnber � <br /> CalRecycle State of cle 181(R 11 - 1177687 <br /> CalRecycle 181(Rev.y(CalRecycle) Survey <br /> Cal Sur Vey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) VV � v �J <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: 1 V 6 © Ll 0 ( ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local '17- If Referral,choose referral type(Fill one) <br /> Identifier: 1XIM �oc,�„�v� L�l/Y1�1 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name _ _V Inspected By Inspector <br /> A%td �a�.,f- <br /> Physical Address 3 C,CA <br /> `IJrp�Q� Inspection Date <�� / '? l � l ^7 TL✓Gift l UT \ u� G <br /> Time In Time Out <br /> Business Rep Title 0 AM o AM <br /> L I ( - :Jti 7 O PM ( 5— 2 O 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 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive ® 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 ® 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 0 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 � Extension <br /> O 0 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 00 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 2 <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities u, <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> 0 0 Other:§ _ -- <br /> Comments <br /> �C.c�C - y <br /> Inspection Form Included: 0 <br /> Comments Included: (S <br /> Business Rep's gnature Phone Number I spe �oh's r ature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: E X A L 112 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co y: <br />