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Waste Tire Su. Bey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle I 1 — 1255777 <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- _ � + Inspection Type(Fill one) <br /> Site Suffix: l io Routine 0 Re-inspection Q Referral Q Observation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identifier: SQV\ �0aQ V�h COV,^�-.r Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name i r <br /> Inspected By Inspector <br /> Physical Address <br /> 2 6C�c) C- o w.: _S <br /> �1S2eS Inspection Date I 7— / ® ` 5 <br /> Time In Time Out <br /> Business Rep \ Title O AM ' ) O AM <br /> {. GN'� � 1�\1�� S !",�h�•�Q2Cv�56'� 1 � � PM L � � �PM <br /> S ` 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 /> 7 0 Active Q Passenger Q Generator a Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive ® Truck <br /> Longitude — Q Planned Q OTR Q End-Use Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 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 <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 EXE N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations <br /> Q Q Other;§ <br /> Comments 1`e—\v` 7 ` C—C <br /> pf2v:c�vCV�o�a'l��nS lamer\ r2C�2C3�- <br /> lv�, o c Al'ea.S (3�- C+c�►�ctc'n . <br /> Inspection Form Included: Q <br /> _tea-a35-131-4 9 y6 <br /> Comments Included: ----- <br /> Bu ess Rep's Sign ure Phone Number Insp ctor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: EXAMPLE 112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA �� ■ <br />