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Waste Tire Su. ✓ey & Inspection Report inspection Report Number <br /> CalRecycle State of California I 1 - 1210 311 <br /> CalRecycle 181(Rev.y(Ca[ Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey <br /> BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection 2.. �y / _ Inspection Type(Fill one) <br /> Site Suffix: —1 b 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �p�y1 �Ch �� co')"-V Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> 55'k Mace - I l }��T v <br /> Physical Address <br /> -Z -32-1 <br /> Inspection Date 2 I 3 <br /> S vocv Var C�4 G520 3 <br /> Time In Time Out <br /> Business Rep Title , <br /> q (� C 4D AM a AM <br /> 1 '\ J 0 PM v v 0 PM <br /> C2Q enc S �21�a. �otna,, (; --- - <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 /> Active Q Passenger 0 Generator 4D Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude 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 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 0 Other ( _a�o V 2ss�e-1 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date MOC <br /> / <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) <br /> 0 Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years c <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 Q In Compliance-No Violations o <br /> Q 1 Q 1 Other:§ <br /> Comments t� <br /> 1�by YNQ ..s G•s k-k= �c-� �rr\,s A 4e- 0 <br /> Inspection Form Included: Q <br /> Comments Included: <br /> Business p's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK [Correct:* Incorrect: �O EXAMPLE 1112 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />