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Waste Tire SAey & Inspection Report .nspection Report Number <br /> CalRecycle state of California81( 11 - 1177752 <br /> CalRecycle 181(Rev.y(Cal Survey Form - Page 1 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- , 7 / _ O Inspection Type(Fill one) <br /> Site Suffix: V -4 0 Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: Q co V O CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> DSL �xVress - 0TT� <br /> Physical Address <br /> Inspection Date S / (00 / <br /> 3 <br /> 5�v <br /> C_\V_ r C c1 S Z 15 <br /> Time In Time Out <br /> Business Rep Title �7 O AM O AM <br /> G o O PM Q * 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 /> �(J Q Active Q Passenger Q Generator Q Outdoor <br /> O 0 Closed O Altered AJC N A <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR O End-Use O 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 O 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 � Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m m N <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or Ex7) N <br /> O Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CalRecycle Enforcement g <br /> Lu <br /> 0 O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities u, <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: ` _ z <br /> Comments V ` k oo s� ``i+`� ``1 S p�0 n t^v%e o in �i S G eLkz <br /> Or a -Cc's O� ronce.ftn <br /> Noyas'1., 11.:s c��� 1r<4s cLssc�l lte�� F-c; C' yn dto a„�w�'c <br /> Ci)29 3�-btiS7�k� Cv�;c�y►n cic� re. Q�eY..m�r<� T SPT 6e close <br /> Inspection Form Included: 0 I)A� q, U <br /> Comments Included: 0 Zd t� 7� -32 g <br /> Business Rep's Signature Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X EXAMPLE 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />