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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 1210 513 <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- Inspection_ O Inspection Type(Fill one) <br /> Site Suffix: (D ® Routine Q Re-inspection Q Referral Q Observation <br /> Local �` , If Referral,choose referral type(Fill one) <br /> Identifier: SGS J OC& V1t n �un Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ""l7 C Inspected By Inspector <br /> �1 CUkManv \ \(Q5 ��(yr� C'1tc�r�(ll,l1���D <br /> Physical Address �J�U�� <br /> Inspection Date l 0 <br /> Time In Time Out <br /> Business Rep Title S O Q AM 3 v 0 AM <br /> ® PM <br /> _ ®PM <br /> � ' O f�eT Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � s <br /> ' ® Active 9 Passenger • Generator 0 Outdoor <br /> GPS Latitude 0 Closed Q Altered <br /> Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> • New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® 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 /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of Violation Q Extension <br /> ® 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 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> 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 <br /> Q In Compliance-No Violations o <br /> Q Q Other:§Q T1 <br /> Comments A A �� 4� S AG C� � m�_ <br /> W�,S fc.. 1 nS anc�/� <br /> Inspection Form Included: O �, /'`�O 1 _ <br /> Comments Included: ® `(Y <br /> Business Rep's Signature lPhone Number Inspe 's Signature Phone Number <br /> INSTRUCTIONS ON BACK [Correct:* Incorrect: IEIXIAIMIPILIEI 1112 N 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />