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Waste Tire Sk .. vey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California 11 - 1178045 <br /> CalRecycle 181(Rev.y(Cal Survey Form - Page 1 <br /> Dept of Resources Recycling and Recovery(CalRecycle) Survey� �r <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ' � � � � � � _ � Inspection Type(Fill one) <br /> Site Suffix: I ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local /� �/�{��Q � (&U�14 <br /> If Referral,choose referral type(Fill one) <br /> Identifier: sJ0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> V-U�Qn Wu�cS �- Sons Q=C\ . 9 <br /> Physical Address C�Cv � <br /> Inspection Date 5 � 3 1 / 1 <br /> 1 LJ{ Time In Time Out <br /> Business Rep Title 0 AM 0 0 AM <br /> PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) / I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �j <br /> *'Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O Q Inactive ®Truck <br /> Longitude - 0 Planned OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair ® 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 I A I HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 Q 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 /> 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) <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 /> 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 <br /> In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments a_o:u:k� 1 hn AMC- (0 Alk, AA,h d N <br /> .(C S00 '- <br /> V i o K�i cv�S r�S _C� 5 G at-o-r n <br /> Inspection Form Included: q <br /> Comments Included. <br /> siness Rep's Signature Phone Number Insp tor's Signature Phone Number <br /> INSTRUCTIONS O BACK �Correct:* Incorrect: ) � VJ E X A M P L E 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:L ® 0 <br />