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Waste Tire S,..vey & Inspection Repo& Inspection Report Number <br /> CalRecycle State of California I 1 — 1 2 4 2 15 <br /> CalRecycle 181(Rev. (Cal Survey Form ® Page 1 Q <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 /> n <br /> Site Suffix: I b _l 6 V 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local C I - If Referral,choose referral type(Fill one) <br /> Identifier: �(i� i/�� C10 `Z/ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name v ( Inspected By Inspector <br /> mcg,-�t,�l cam.. 0 •� j lot �1 i�I Y�1�'i t <br /> Physical Address Q <br /> 3�6 l A,�v C ca kir CrY <br /> Inspection Date -7 <br /> Time In TimeOut1 J <br /> Business Rep Title 0 AM ®AM <br /> �i c.�h V' ►� 4~ta h� � U,tmc r <br /> 0 . 41 (`j Q PM 3 Q 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 /> 55 ® Active ® Passenger 0 Generator Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR 0 End-Use Q Container <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer 0 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 Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> 0 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 0 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 EX7) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> Q ` LL Cry: <br /> i/ <br /> Inspection Form Included: 11 <br /> 1'16 7 7 <br /> Comments Included: ® <br /> u es p's Signature Phone Number lAsdect s Si ature Phone Number <br /> - - -_ - <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X EXAM E 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co y: <br />