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Waste Tire Su. ,iey & Inspection Report inspection Report Number ■ <br /> State of California <br /> CalRecycle I 1 " 1196278 <br /> CalRecycle 181(Rev.y(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- � � q - � I Inspection Type(Fill one) <br /> '3 � � <br /> Site Suffix: I ` 10 Routine Q Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SOLh �O V CG` L , Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name f Inspected By Inspector <br /> Com Y\f-r v�Ga�S g m 1 0 <br /> Physical Address U <br /> 3` c)o wa5v%ec �\�5�n <br /> Inspection Date O 1 / Z <br /> Olt k C gS2aq <br /> Time In Time Out <br /> Business Rep Title ' O O ID AM i ' <br /> 0 PM I Q PM <br /> a `Nl �C�0. - - �� � �' Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 00 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active Q Passenger Generator I* Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude 0 Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned 0 OTR 0 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 0 Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station 0 Hauler Q Agriculture Q Shredder 0 Other t l � <br /> �1 <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS t <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 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 m <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 /> n <br /> v <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 /> 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 /> 0 1 O1 Other:§ <br /> Comments <br /> Inspection Form Included: Q � r �(,J� 2ol-100-32 8 / <br /> Comments Included: �0 �J - <br /> Busi es ep's Signature Phone Number Inspe tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK [Correct:* Incorrect: X �0 V I IEIXIAIMIPILIEI 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />