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02 Waste Tire Su. ✓ey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California 11 - 1177857 <br /> CalRecycle 181(Rev. (Cal 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- ` a a _ Q 1 Inspection Type(Fill one) <br /> Site Suffix: O ®Routine Q Re-inspection Q Referral Q Observation <br /> Local ; R �� � If Referral,choose referral type(Fill one) <br /> Identifier: SGlC1 J O u n U9 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> C�,� aVes as ('C1 u,�'�s'►a�S, 1nL_ p _ /-� <br /> Physical Address <br /> Inspection Date / 0 -7 / <br /> IS-I30 r 013 � Time In Time Out <br /> Business Rep Title O AM Q AM <br /> D,' 5 ® PM S 0 PM <br /> �ni5on SUIeS Q�Q. <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 /> 8 Active Q Passenger # Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® 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 9 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 11 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 0 Other GIC-f-k� (y)QnU�tU(7--_►fcf <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 /> Q Q 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 a <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <br /> r <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:§ 1 , l 1 l- l <br /> Comments 1 ��' W b, UP A 1'111 A UV,L U�lUX I► l `) O1117Wjf) <br /> flt. 1 n9 n r �t�. � Il �� <br /> SUS <br /> — <br /> Inspection Form Included: Q <br /> Comments Included: © <br /> Business Rep's Signature Phone Number Insp tor's Signature Phone Number <br /> �(- <br /> INSTRUCTIONS ON BACK Correct: Incorrect: � Wn NJ E X 62081 <br /> A L E , I 1 12 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink op <br /> y: �� ■ <br />