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Waste Tire Su. jey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle 1 1 1177730 <br /> CalRecycle 181(Rev. (Ca] 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- Inspection Type(Fill one) <br /> Site Suffix: >b 6 - 0 <br /> * Routine Q Re-inspection Q Referral Q Observation <br /> Local .- If Referral,choose referral type(Fill one) <br /> Identifier: h 3 o,,,^ V�h cc010- � Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 Inspected By Inspector <br /> �aCS;'S�_ s q - t a L M AT TO <br /> Physics dress <br /> ZZ t E J11 ac Po Sal <br /> A %2_L5 Inspection Date 5 / I 2 I 3 <br /> Time In Time Out <br /> Business Rep`` \\\ Title 0 AM0 AM <br /> �1 C K �6 1C•h �0� / " l �, l I �� � 0 PM � 1 � � Q PM <br /> C w 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 • Generator Q Outdoor <br /> GPS Latitude O Q Closed Q Altered Q Hauler Q indoor <br /> o <br /> O Q Inactive ,Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 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 A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> 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 a <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> a <br /> 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 W <br /> Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> 0-4 4^2 .0 C- ti s <br /> une A C, a <br /> Inspection Form Included: 10-(-�, ,fp � �3 , /O�jo10 <br /> Comments Included: <br /> 4w, <br /> G %fps ' <br /> Business Rep's Signature Phone Number Inspe is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: EjXjAjMjPjLjEj <br /> 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />