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Waste Tire Su. ey & Inspection Report inspection Report Number ■ <br /> CalRecycle State of California 11 - 1196668 <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- 0 1 Inspection Type(Fill one) <br /> Site Suffix: ` 0 Routine Q Re-inspection Q Referral O Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: S a h �b0.Q V%V\ U� O CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 t <br /> Inspected By Inspector <br /> J-'?> \AvYA TccL•r\SeockS - O <br /> Physical Address 1 <br /> ` Inspection Date <br /> S -oc,��n 9 SZC� <br /> Time In Time Out <br /> Business Rep Title [ [ 0 AM 9 AM <br /> n UU c D ✓ J 0P I O QPM <br /> 'VWXY\ ✓ fo e'ZN -� 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 /> 0 Active O Passenger &Generator Q Outdoor <br /> Q Closed O Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> C Q Inactive 40 Truck <br /> Longitude — Q Planned Q OTR O End-Use Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 Trucking Fleet 0 Government Q Retreader 0 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 /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> N <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CalRecycle Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •in Compliance-No Violations o <br /> O O Other:§ <br /> CommentsCe— \YNSee C?r-zOcv, <br /> Inspection Form Included: <br /> Comments Included: <br /> Busin s Ignature Phone Number Inspector's signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: � g E X A M P L I E 1 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA �� ■ <br />