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Waste Tire Sup vey & Inspection Report Inspection Repor,Number ■ <br /> CalRecycle State of California 11 - 1229989 <br /> CalRecycle 181(Rev. (Ca[ Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> 'art A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- G C> -7 _ O Inspection Type(Fill one) <br /> Site Suffix: J . Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: ��jJY\ 0( `j V^� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name – ``/ Inspected By Inspector <br /> S--C11 f_tcoo c_ �l Mcg`�ce - d I /`/` �`�' V <br /> Physical Addre s <br /> Inspection Date O 2 <br /> / / a 6 / 1 S <br /> K— Time In Time Out <br /> Business Rep Title 0 AM C.� 0 AM <br /> �yC�n� 1 2f d PM I S PM <br /> 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 10 Passenger 06 Generator Q Outdoor <br /> O Q Closed 0 Altered /" /A <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 40Truck <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 0 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 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q 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 /> Q Notice Of Violation Q Extension <br /> Q Q 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 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years N <br /> 0 <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 O 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 /> 6V o ���o`c��!�cmS r3 t �c2�5 � �v�c'e t'✓1 <br /> Inspection Form Included: Q U <br /> Comments Included: �Signature <br /> ��tom'Busi Phone Number Ins pec is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:4D Incorrect: X EXAMPLE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ■ <br />