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Waste Tire o0gl ey & Inspection Repo.t inspection Report NumberState of <br /> ■ <br /> Cal Recycle CalRecyclel1fornia 181(Rev.10/10) 11 - 1176455 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 <br /> Part A-Survey_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ` � � � � � � - yl � Inspection Type(Fill one) <br /> Site Suffix: I 1(J 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local � � /i, �-}� If Referral,choose referral type(Fill one) <br /> Identifier: a Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> SGI� 040 ' S �� fs `1' Q lPhysical Addre 6en �v /� <br /> ��� Inspection Date <br /> © LA 5-110 <br /> Time In Time Out <br /> Business Rep lTitle OVI) o V lo O AM O j> O AM PM <br /> U4(,k Splq(�(1l0 QW31n ef— --PM <br /> J 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 Q Active Q Passenger Q Generator Q Outdoor <br /> O ® Closed Q Altereedd�A A)J.1 ./in <br /> GPS Latitude 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 /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 0 Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber II < <br /> Q Service Station Q Hauler Q Agriculture Q Shredder * Other &J Sl6L_ &rv1 r c. <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 6_0 § - — Q Notice Of Violation Q Extension <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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle Cl) <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <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 /> 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 In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> A �t) A)'N rq U)74 S p ; <br /> Inspection Form Included: Q <br /> yah-4357 <br /> Comments Included: <br /> B s Rep's Signature Phone Number Inspect 's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON B K Correct: Incorrect: NJ "Pink <br /> Vpy: <br /> 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator © . <br />