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Waste Tire SI,.. ✓ey & Inspection Report Inspection Report Number <br /> CalRecycle State of California( I 1 - 1255856 <br /> CalRecycle 181(Rev. y(Cal Survey Form - Page 1 <br /> Dept of Res ources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- t l� ` _ ` Inspection Type(Fill one) <br /> Q <br /> Site Suffix: 1 1 1 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �OG�%3 Y% (Q V Y1 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> �)o(-CDA (Yr0_VnS1�6c�— �I l C� 1 /Vl T U <br /> Physical Address <br /> Inspection Date <br /> S'�GCV�t ova Time In Time Out <br /> Business RepTitle`"5(CLC, �. O AM O AM <br /> 170p C0.�SC OW`���Y�2C- � � � ® PM I � � 0 PM <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) I �7 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> •Active Q Passenger Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler S Indoor <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 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 ® 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 PRC§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 O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> E <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance-No Violations o <br /> Q Q Other:§ <br /> n <br /> Commentsart, <br /> u <br /> 1` r .` ` <br /> Inspection Form Included: Q <br /> Comments Included: 14a"L 44e �T y&' 3zg <br /> Business Rep's Signature Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: >� IEIXIAIMIPILIEI 1112L3j 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />