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Waste fire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of California p ryry I l - 1196608 <br /> CalRecycle 181(Rev.y(CalRecycle) Survey <br /> S1 rvey p.orm — Page 1 <br /> Dept of Resources Recycling and Recovery(CalRecycle) {•!� V�s Form��! Page <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- t 1 3 - ® Inspection Type(Fill one) <br /> Site Suffix: `� +Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 20-Y\ � q VCS C_(�)U � � _ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> \�a1,1eY r-������-� 3 11 <br /> Physical Address <br /> Inspection Date <br /> Cj�\ g52oS <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> \ , ' © * PM PM <br /> "evkY\, �Q �r 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 /> O Active Q Passenger • Generator 1* Outdoor <br /> O Q Closed Q Altered <br /> _GPS Latitude Q Hauler 0 Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned ' OTR Q 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 Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber l <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 16 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 / N <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 EXE <br /> A <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 /> 2 <br /> Lu <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance-No Violations o <br /> Q Q Other:§ z <br /> Comments0le\ <br /> Inspection Form Include4BA <br /> Comments Include <br /> �Correct: <br /> p's Signature Phone Number Inspe tor's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONI& Incorrect: IEIXIAIMIPILIEI 1112 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />