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Waste Tire Su. ,✓ey & Inspection Report inspection Report Number <br /> Cal Recycle State of California I 1 1196638 <br /> CalRecycle 181(Rev. (Cal 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: ' 6 ( 8 7 - 01 • Routine Q Re-inspection Q Referral Q Observation <br /> LocalSam J��v� If Referral,choose referral type(Fill one) <br /> Identifier: l% Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> irl LA Corn Q j 3 �l l © Al2 Y�'I P, <br /> Physical Address <br /> Inspection DateA Q5 <br /> Time In Time Out <br /> Business Rep Title O AM �J AM <br /> n . � O QPM ` 0 ® PM <br /> U, 1nn� L.Gi�J Vl DC? Clef-�-� �((�f'i <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 a Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude 10 Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use 4b Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q 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 ®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 Q PR § - �Notice Of Violation Q Extension <br /> C 42951 Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> . Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / M,-)- -7 / F <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 g <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 <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: 0 I(*Uio <br /> Business Rep's Signature APhone Number sp ctor's ig r/ature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E X A M L E 11213 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop :1_41-" <br /> © ■ <br />