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02 Waste Tire SIkey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1242341 <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- ' � rt � p � � _ � ( Inspection Type(Fill one) <br /> Site Suffix: Q Routine Q Re-inspection Q Referral Q Observation <br /> Local r— If Referral,choose referral type(Fill one) <br /> Identifier: SCko J Q('a q 1A.,1 fl '-n Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name _ l <br /> Inspected By Inspector <br /> PO A to is TQ ks 3 <br /> Physical Address <br /> 2305 S - All c?U rl L/U�- <br /> �� G ��r^� Inspection Date <br /> V v l W Time In Time Out <br /> Business Rep (� Title ' 1 AM I 5 O P <br /> AM <br /> ` Q�jO `SfnL��iT�Lv �1J1)�1e1` O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) S � Jr <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � <br /> 0 Active ® Passenger S Generator ® Outdoor <br /> 0 <br /> GPS Latitude Q Closed Q Altered <br /> Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude – Q Planned If OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer 41 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 <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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle g <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE 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 /> f <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 Q In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments ' <br /> r\o-, i Ic, 1 r1 TS l� <br /> OWN _ <br /> Inspection Form Included: * _5)-7t <br /> (ZOIAg— <br /> Comments Included: ® I 8�9 <br /> usiness Rep's Signature hone Number Ins– <br /> ?U' c or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A M 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop L <br />