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Waste Tire Su. .ey & Inspection Report aspection Report Number <br /> CalRecycle State of cle 181(R I 1 - 1210453 <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- I C A _ O l Inspection Type(Fill one) <br /> Site Suffix: J b 41 Routine Q Re-inspection Q Referral Q Observation <br /> Local �p If Referral,choose referral type(Fill one) <br /> Identifier: S G o T 07'1 y Ltl) r rN b'%A_0►,J Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 6 <br /> Inspected By Inspector <br /> UIQ 1 <br /> r 0uP 3 - o <br /> Physical Address <br /> um) <br /> C <br /> Inspection Date p / 0 <br /> � �1SZc��, dill �/ <br /> Time In Time Out <br /> Business <br /> �Rep Title 1 O O AM /n O AM <br /> es <br /> J 1 e v, L zi A p 1�, 3 O 0 PM 3 v ® PM <br /> t �' 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 0 Active Q Passenger 0 Generator Q Outdoor <br /> Latitude O Q Closed Q Altered lJ 7A <br /> GPS Q Hauler Q Indoor <br /> o Q Inactive Q Truck <br /> Longitude — Q Planned ® OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) - <br /> Q New Tire Dealer Q Auto Repair Q 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 1 1 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder &Other 11Q U qIe�lU x' <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 N <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 EXT) n <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 _ _ m <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:§ <br /> � z <br /> Comments Q.,) -s C' �` I ' ' <br /> wms <br /> 0i <br /> Inspection Form IncludeQ '/ ��7 <br /> ��� � �d� ,1 ��� <br /> Comments Included: P �t <br /> Business Rep's Signawrtr Phone Number Inspec o 's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect: E X A L E 1 2 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink C 0 <br />