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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of California I 1 - 1242271 <br /> CalRecycle 181(Rev. (Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- r 2 3 S 4 Inspection Type(Fill one) <br /> Site <br /> Site Suffix: 10 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �O�'ry O�V1 co V 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> C C \G►-s �,"A 9 o <br /> - <br /> 3 r t MA-V T V <br /> Physio I at e Address <br /> V5 3co M c kN-:"\P'y <br /> Inspection Date U Z / O <br /> t-c�.'rl.,coe cd� 95 330 <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> ' V J 0 PM ® PM <br /> �ecos�.c� AJ oJ,oS Fo <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> r (0-3 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 40 Indoory <br /> 0 0 Inactive 0 Truck <br /> Longitude — 0 Planned OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other e' myC'N ICQf <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> Q 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> Q 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators IS In Compliance-No Violations o <br /> O 0 Other:§ <br /> Comments <br /> -. IL O's = <br /> �o1p Sj.o�,o��.orS �,� cesxS o� Ccs�ch <br /> Inspection Form Included: 0 a 91(0(O ���f <br /> Comments Included: L� ro <br /> Business Rep's Signature Phone Number Insp toy's Signature Phone Number <br /> orrect: Incorrect: M � EXAMPLE 1 273 62081 <br /> INSTRUCTIONS ON BACKFc <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />