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Waste Tire Suevey & Inspection Repo Inspection Report Number <br /> CalRecycle State of California 11 - 1255792 <br /> CalRecycle 181(Rev. (Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Su_rvey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 3 G� � Inspection Type(Fill one) <br /> Site Suffix: / I © Routine Q Re-inspection Q Referral Q Observation <br /> Local �` If Referral,choose referral type(Fill one) <br /> Identifier: so-Y-1 ''v v bath Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> )s ��✓a cam.. ,a�i cam. . -�key �1 - o / <br /> Physical Address � ' Sf�l'U��/�L <br /> 102-4 y11e.�tc}-r� <br /> Inspection Date .� o 1 <br /> 1r'VC �� `.j ✓� 7 <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> `�Y) S70PM � � � ® PM <br /> _ �1 uil�S 4?m <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 /> 0 Active Q Passenger ® Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive • Truck <br /> Longitude — Q Planned Q OTR a End-Use Q 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 Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I 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 <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 /> 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 /> W <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 In Compliance-No Violations o <br /> Q 1 Q 1 Other:§ <br /> z <br /> Comments LP' <br /> Inspection Form Included: 01 <br /> Comments Included: <br /> "ned: p's ignature Phone Number frispe-ctor'solSignature Phone umber <br /> INSTRUCTIONS ON BACK Correct:40 Incorrect: E X A M P L E 1 2 3 62081 <br /> . White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />