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Waste Tire Su vey & Inspection Repo doinspection Report Number <br /> CalRecycle State of California I 1 - 1245033 <br /> CalRecycle 181(Rev.yCal 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 Type(Fill one) <br /> Site Suffix: 1 .2709 <br /> z d 9 2 L 0 1 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local n If Referral,choose referral type(Fill one) <br /> Identifier: Sari Vh�y 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> �CCvC� Sec�,�c� ti .. I n _ t <br /> Physical Address ` Y �� C, - � M , \ 1 ) <br /> 1 _ 1 Inspection Date O U <br /> S'T oG� rC71/� GS2a6 Time In Time Out J <br /> Business Rep TitleO AM O AM <br /> Z sis PM • 6 PM <br /> 9 \ 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 40 Closed 0 Altered,� <br /> GPS Latitude A) /"c 0 Hauler 0 Indoor <br /> 0 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 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 /> 0 0 § - 0 Notice Of Violation 0 Extension <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 /> 8PRC§42956-Registration/Decal in Vehicle <br /> 0 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 E)C7) N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> w <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <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 /> CommentsAZ v,S-t SPGL�t+�h o TL.: p�Q n Y` (� <br /> N'VA51I'X �O1p,S a g�__C �� ` • <br /> e ti,QQ1 <br /> 1 4 3:31 <br /> - <br /> Inspection Form Included: <br /> Comments Included: <br /> Business Rep's Slulinature Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK �orrect:* Incorrect: �* Incorrect: EXAMPLE 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />