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Waste Tire Su, vey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CalRecycle 11 - 1196648 <br /> CalRecycle 181(Rev.y(Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A=Survey - —-- — _-- ___—__.. BLUE_OR_BLACK INK_P-EN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: 1 -7 19 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local C8 If Referral,choose referral type(Fill one) <br /> Identifier: SO VL �✓11� ✓tom 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physica:2dre s f I � <br /> 1 t� 1 AQ-0,6&IL A-- <br /> Inspection Date / Z / 3 <br /> 01 q53�L <br /> Time In Time Out <br /> Business Rep Title _ <br /> 0 AM (� AM <br /> ' ( S 0P l 'QPM <br /> �a� ---- ✓ Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) C/ (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active ® Passenger ® Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 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 /> New Tire Dealer ® Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> ® 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 /> § <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 /> PRC§42956-Registration/Decal in Vehicle <br /> 0 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 EXT) n <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> Lu <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities u, <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 /> Comments <br /> Inspection Form Included: 0 <br /> Comments Included: ® ! - <br /> Bu ' es Reps Signature Phone Number I p tr' Si nature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: E A L E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />