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Waste Tire SL%ey & Inspection Report . Inspection Report Number <br /> CalRecycle State of California 11 - 1255728 <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- I _2d _ Inspection Type(Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identifier: S�h �G �y v`� ��t,`! Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name v`"� <br /> Inspected By Inspector <br /> a ��5 �v�sk 1 �\�Y bc►.�;�.sav� - 1, c) 1 M"&I TTv <br /> Physic Address �� nn <br /> ��hCC �,� �533a Inspection Date ` t � 09 <br /> Time In Time Out <br /> Business Rep Title IAM 1 A Q 0 AM <br /> S 0 PM "� *PM <br /> VG �• <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 Q Passenger 4111 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Indoor <br /> 0 Q In Q Truck <br /> Longitude - Q Planned • OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber. <br /> A�� �•1 � <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 48 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 <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 O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <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 EXE N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> f <br /> W <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators t In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments AA,-t—s <br /> 4 - e -�r� i �:v� itis vacs\�a-�• <br /> o(- keas eeT- 6v\.r_4E1_('h <br /> Inspection Form Included: Q ���,�'� Phone N$__E2 I <br /> U <br /> Comments Included. - - <br /> �{l <br /> ess Rep's Signature Phone Num Inspec is Signature umber <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: zX EXAMPLE I 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA �� ■ <br />