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Waste Tire Su, vey & Inspection Report inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1242129 <br /> CalRecycle 181(Rev. (CalRecycle) <br /> Surrey Fora - page 1Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: l �-( 23 F; C' C) Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local `` � ! If Referral,choose referral type(Fill one) <br /> Identifier: �A �(1�1�b�� Com' 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> qct 0 l3 i'hG1,✓ufl f.v 1 <br /> Physical Address - l c <br /> Inspection Date y <br /> Qsao S" <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> (AQkev A�,t v2 • —)LG oPM - -) ' 75 0 ®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 /> It Active 0 Passenger ®Generator ®Outdoor <br /> O 0 Closed 0 Altered <br /> G PS Latitude <br /> Hauler Indoor <br /> O 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 <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 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation Extension <br /> 0 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 M / M / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXI <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w— _ <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> ®In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments ` <br /> cul,14,24 <br /> Inspection Form Included: 0 !�9 94,,'3.�366 <br /> Comments Included: p �6�Pb 73 <br /> Business Rep's Signature Phone Number ns ec r s 1 a re Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: R*Y] E X M P E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy: <br />